Subject: Fatigue

From: Lisa

Message: 

I am a 24-year-old female recently married, with quite a busy life. I have a healthy body weight and no significant health problems. For the last six months I have noticed an increase in fatigue. I am constantly tired (exhausted) all day long and have trouble staying awake when I get home from work (around 6:30pm). I get about 8+ hours of sleep a night and eat quite healthily. Is there anything you can suggest to help me boost my energy level. I have considered taking vitamins, however I am not sure about which ones would benefit me most. I have also considered exercising a little more often, however because I am so exhausted all the time I find it extremely difficult to build up the motivation and energy to get out.

Please offer suggestions.

Reply from Dr. Bazos:

Dear Lisa:

Thank you for your important question. You have supplied me with enough information to recommend that you make an appointment to see your doctor. Fatigue is certainly one of the commonest complaints presenting to any primary care physician. During the 5 to 20 minutes that your doctor spends with you eliciting a history and performing a physical examination and deciding if further testing is necessary there should be a myriad of thoughts passing through his/her head. If you wish to grasp the general nature of what and how trained doctoring processes works, if you wish to become involved in your own health and in the decision process of working with your doctor in keeping with the "Healthcoach philosophy" then read this entire answer, which I'm sure you'll find informative and useful. Otherwise you may skip down to the bottom summary paragraph and let the doctor be doctor and you just listen and do what he says. Yes, it will take some time to read, and more time to absorb, but you will gain some accurate understanding and insight into how our remarkable bodies function, and just how do their feedback and regulatory mechanisms balance in such a way as to stay fit and healthy in a stressed and toxic man-made ecosystem. I challenge you to commit yourself!

I choose to categorize the many causes for fatigue under the broad headings of organic (e.g. medical), psychiatric (e.g. mental health related) and psychosocial. 

A. ORGANIC: 

1. Vitamin C Deficiency

Without vitamin C the body fails to produce enough adrenaline, adrenal hormones (corticosteroids), neurotransmitters (the chemical substances which are released at the ends of communicating nerves or neurons), and other similar substances, which help maintain normal cellular functions. These all manifest themselves in the primary early symptom of fatigue.

Vitamin C Deficiency is an overly abused term. I'm really referring to a "negative vitamin C balance" in which you may be losing too much vitamin C even though you're taking in enough nutritionally. How can this be? Well, you never mentioned whether you are a smoker. Smoking is the number one vitamin C enemy (antagonist). Cigarette smoke destroys vitamin C at a rate essentially more rapid than it can be consumed. A single cigarette alone may consume as much as 40 mg of vitamin C. One pack of cigarettes literally 'eats-up' 700 mg of vitamin C; 2 packs 1400 mg, and so on (puff!!). It is virtually impossible to consume enough vitamin C to balance and neutralize that many cigarettes. Thus smokers, even without considering any other vitamin C destroying factors, suffer from an extremely dangerous condition: a totally negative (less than zero) vitamin C status, a condition which leaves oneself highly vulnerable to a vast range of severe illness (acute and chronic), including infections of the lung (bronchitis, pneumonias, colds), emphysema, asthma, systemic infections, liver and blood diseases, coronary artery disease, chronic arthritis, and, of course, the big "C word" in almost every brand (imported or exported). Once again, all of these mentioned conditions almost invariably exhibit symptoms of fatigue. 

What about passive smoke? Well, if you're in the same room with cigarette smokers, studies show that you will 'lose' many millions of molecules of vitamin C every time your fellow smokers light up. You may want to take an extra vitamin C tablet every time you seat yourself in the 'non-smoking' section of a restaurant.

O.K. you may not be a smoker, but what about stress and vitamin C? Stress (very simply) causes a generalized hyper-metabolic state which causes vitamin C to become rapidly consumed within the body and has been measured in greater amounts excreted in the urine.

Now, to add insult to your self-destruction, most smokers consume artificial 'uppers' to combat the fatigue including large amounts of coffee, refined sugar, and later in the day alcohol, all of which oxidize and further 'eat up' any lingering vitamin C that the 'smoking-gun' in you system may have missed. Sound familiar? There is a long list of many other substances which inactivate or destroy vitamin C by a process called oxidation. Some of the commoner vitamin C destroying enemies include: antibiotics, aspirin, many of the anti-inflammatories (NSAIDS, Motrin, Advil, Indocid, Voltaren....), antihistamines, carbon monoxide (exhaust fumes), black tea, MSG, birth control pills, smoked foods, deep-fried foods, toxic oiled French fries, junk foods and even microwaves, to name a few.

But Lisa, why take vitamin C when you 'eat well' you say? Let's consider that a moment. Citrus fruits are high in vitamin C only if they are eaten right off the tree (try it and see the difference next time you're down in the 'Ole South'). Most commercial citrus fruits (grapefruits, oranges and tangerines) are picked green and ripened in large warehouses. They are artificially ripened in these warehouses with bromine gas (it's true, believe me). Bromine gas is a noxious toxic poison to all life. Then again don't forget that the fruit was also originally exposed to fumigants and pesticides prior to shipment to prolong their 'freshness' and shine. In contrast, natural sunlight is a safe nontoxic ripening agent which dramatically increases the synthesis of vitamin C within the fruit. Thus, because citrus fruits are not tree-ripened, their vitamin C content is reduced significantly. In some instances these fruits contain no measurable amount of vitamin C at all, but boy do they shine! Further add vitamin C loss due to transport, storage, plus the fact that fluorescent light destroys vitamin C, and you can easily understand that it is possible to purchase citrus fruits devoid of any viable vitamin C.  Even commercial orange juice, thought to be an excellent source of vitamin C, may contain little or none. The reason being that the cooking, pasteurization, and storage processing, as well as the addition of synthetic preservatives, destroys much of the vitamin C content. 

It's no surprise then that the typical North American diet is highly vitamin C deficient, triggering many of the above mentioned ailments, often presenting as mere fatigue.

By now I may have convinced you to consider a vitamin C supplement, but which one and how much? To be on the safe side consider 500 - 1000 mg vitamin C twice daily and increase consumption of 'natural' foods rich in vitamin C. If you wish to consider higher doses of vitamin C, then discuss the dose and type with your doctor. Vitamin C can accumulate in the kidneys and precipitate kidney damage or even stones, so you must drink adequate water to improve its elimination (minimum 1 liter per day). Avoid refined sugar and reduce intake of caffeine and alcohol. If you are a smoker than observe the following: In Canada smokers die of chronic health problems related to cigarettes, whereas Americans get shot at the variety store trying to buy a pack of smokes. It's your choice!

2. Iron Deficiency Anemia:

This term is usually self-limiting in a situation such as yours. It implies that anemia is due to less than normal quantity of iron (Fe, Latin for ferrous) in the body. Iron deficiency is common in young women even in the absence of anemia. It simply means that your iron stores have been reduced (sufficiently enough to cause clinical symptoms of fatigue) but that your serum iron concentration and blood hemoglobin remain within the normal values. Iron is one of the largest minerals in the body (molecular weight 55.8), and thus may be difficult to be properly absorbed. High acid foods such as tomato sauce, lemon juice, vinegar, and citrus fruits (oranges, lemons) greatly enhance absorption. Also, vitamin C greatly potentates the absorption of iron. High dietary sources of iron include organ meats (liver, kidneys, lung, even 'haggis' if you're Scottish, 'mageritsa' for the Eastern block), red meats, blackstrap molasses, oysters, almonds, cocoa powder, caviar (yeah right!), pistachios and dark green leafy vegetables. Remember that iron deficiency is best confirmed by blood tests. If you are concerned about being iron deficient, see your doctor and determine if you warrant such blood tests. If so, then they should include a serum iron level, iron-binding protein, and a serum ferritin level. Ferritin is the main storage form of iron in the body and is an excellent indicator of the total body burden of this nutrient. If you are mildly iron deficient then it's probably a good idea to take a vitamin-mineral tablet containing iron (18 mg per day) and increase the consumption of iron-rich foods compatible with your system mentioned above. 

Now, If anemia is also found in your blood (e.g. a low hemoglobin of less than 13.0 Gm in women (since they menstruate) and 14.0 Gm in men), then you will also require additional iron supplement (e.g. ferrous fumarate 20 mg twice daily, or other iron preparations such as ferrous gluconate 3 tabs daily or I especially prefer Slow-Fe (1 to 2 tabs daily) due to its gentler stomach side effect profile). In this case it's probably wise to take 500 mg of vitamin C with the iron, since it greatly potentiates the iron absorption (you can take less iron with more of it going to your system; remember iron can be queasy on the stomach and tends to darken (not blacken) your stool. The addition of a multiple vitamin-mineral tablet with 4 mg copper and extra B-complex would also benefit this scenario. If you can afford it "organic liver" (aka provimee liver, that's cows fed milk and natural foods with no additional hormones, pesticides or other toxic substance during breeding), is an excellent source of natural iron. This will surely 'mooove' you to a heightened state of energy. However, most importantly, if you do have anemia (low hemoglobin) and low iron, you can NOT just treat the problem 'blindly' without knowing the cause. You MUST determine the CAUSE of the anemia. In your situation common things are common and we can assume anemia due to menstruating blood loss, but must be aware that there may be one of a many causes of anemia (e.g. blood loss, low intake, problem absorption, problem digestion, or excess elimination (e.g. a leak (stool, in the blood, urine, nose-bleed, vagina etc.). Youre blood must be followed by your doctor and if the numbers don't respond appropriately, then your in for a full battery of more extensive testing (e.g. Pap smear, urine tests, rectal exam which may warrant more invasive testing such as barium enema and/or colonoscopy or gastroscopy to determine the source of any blood loss)

3. Vitamin B-12 Deficiency or Anemia

Vitamin B-12 is also known as cobalamin. This name was coined after it was first discovered that B-12 naturally contains the mineral cobalt. In fact, a cobalt deficiency in the soil may indirectly induce B-12 deficiency within animals.

Vitamin B-12 is required for the function of all nerve fibers, particularly the peripheral nerves. Thus, symptoms relative to the function of the brain (even though the average person uses less than 3%), spinal cord, nerves, and muscles often dominate the clinical picture of B-12 deficiency. It's no wonder that fatigue, confusion, poor concentration, depression/anxiety, irritability, weakness, loss of balance, numbness of legs, feet and hands, agitation, lack of motivation are of the cornerstone symptoms how B-12 deficiency presents.

Dietary vitamin B-12 is found exclusively in foods of animal origin, and the top sources are organ meats, muscle meats, poultry, fish, eggs, and milk products. Seaweed and fresh-water algae are the only known plant sources of this vitamin. But, evidence suggests that the absorption of B-12 from seaweed and algae is considerably less efficient than animal sources.

Now B-12 unlike most other vitamins requires a cofactor for it to be absorbed properly in the gut. This cofactor is called 'intrinsic factor' and is produced in the liver, which is essential for B-12 absorption. In the old days it was taught that B-12 can only be given by intramuscular injection, which by-passes the stomach, is directly absorbed into the bloodstream and avoids the intrinsic factor route altogether. This was later proven to be false and B-12 can be adequately taken by pills. In my office, however, I do on occasion give patients a jump start-boost of B-12 injections, say 2 or 3 shots of 1cc IM B-12. This gives the patient an immediate boost to help get them on the right track and improve compliance afterwards. Indeed, some of my descriptive patients refer to this as their "B-52" shots!

Definitive evidence of B-12 deficiency may be difficult to substantiate in the lab. Blood tests are advisable and should include at least the following: Hb (Hemoglobin), RBCC (Red Blood Cell Count), MCH (Mean Corpuscular Hemoglobin), MCV (Mean Corpuscular Volume), MCHC (Mean Cell Hemoglobin Concentration), and of course a serum B-12 level. These big names are plugged into varying equations to determine whether indeed an anemia is present, and if so help the clinician determine the actual cause of the anemia (e.g. iron or B12 deficiency, thalassemia, malnutrition, toxicity, hemolysis, or chronic illness). If your symptoms complement the biochemical deficiency than a multiple vitamin-mineral tablet containing B-12 on a daily basis is justified. Increase consumption of foods rich in B-12 including eggs, liver, lean red meats, and whole milk products. Eat liver at least twice per week, again the liver should be 'organic' as described above in the iron section. Avoid pork liver to prevent possible trichinosis parasite infection. Cook the liver no more than medium or medium rare, otherwise you will inactivate the most biologically active component, i.e. ,the intrinsic factor. Avoid any alcohol, since it destroys B-12 as well as decreases its absorption. Eliminate refined sugar from the diet. If you have a chronic smoldering B-12 deficiency than you should also take a folic acid supplement (say 5-10 mg daily). Folic acid greatly enhances the utilization of B-12. More to say about the importance of folic acid during another topic of prenatal vitamins I'm currently preparing.

4. Endocrine-Metabolic Problems:

Endocrine causes of fatigue are pretty well all treatable. They commonly involve an imbalance in hormone production (too much or not enough) produced by the following glands: the thyroid, endocrine part of the pancreas gland, adrenal glands, parathyroid or pituitary glands.

a. Low thyroid (Hypothyroidism): 
Hypothyroidism is the condition resulting from a lack of the effects of thyroid hormone on body tissues. Since thyroid hormone regulates many cellular processes, a thyroid hormone deficient state has many many detrimental consequences. Now, Lisa, if you do have this condition you probably would have some of the many other associated symptoms such as: temperature intolerance, cold limbs, weight gain despite reduced food intake due to slowed metabolism; dry skin with brittle hair; constipation is common. Anemia's reduced cardiac output with a slow heart rate (bradycardia) also contributes to the fatigue. Sore joints (arthralgias), swollen joints (effusions) and painful muscles (myalgias) are also seen. There are many effects on the nervous system due to this disorder including: forgetfulness, reduced memory, mental slowing, and depression. Reduced hearing, carpal tunnel syndrome, unsteadiness and numbness are also found with hypothyroidism. This condition is usually screened best by measuring blood serum TSH (thyroid stimulating hormone). However, if suspected your physician should also perform a free T4 index as well as a serum thyroxine T4 to diagnose early and subtle hypothyroidism. 

b. Sugar Diabetes (Diabetes mellitus): 
Diabetes can occur at any age. Its cause is believed to be multi-factorial (i.e. genetically predisposed, autoimmune antibodies, viral antigens, and other environmental triggering mechanisms). Similarly the destroyed beta cells of the pancreas become incapable to produce the insulin hormone. Hence the body has a diminished capacity to incorporate blood sugar (glucose) into the cells. The result is a high concentration of glucose in the circulation causing primary and secondary damaging effects to target end-organs (e.g. eyes, heart, kidneys, and nerves, hence producing caloric wasting and fatigue.) Other classic symptoms of new onset diabetes mellitus includes the triad of weight loss, polydipsia and polyuria. Once again readily determined with a fasting blood glucose test. 

c. Addison's disease(Adrenal Insufficiency,Hypoadrenocortisolism): 
Here it is the adrenal gland, which fails to produce cortisol (the body's natural cortisone hormone), resulting in profound fatigue, accompanied by weight loss, anorexia, nausea and vague abdominal discomfort. The earliest signs of this disease may be nothing more than an increasing severity of a minor illness, such as excessive fever or a prolonged duration of the common cold. Ironically, the late JFK suffered with Addison's disease, although 'Norma Jean", and others I'm sure would argue that he had any symptoms. Once again this important diagnosis is determined by means of specialized blood tests including the plasma level of ACTH hormone in the morning (between 8-10 A.M., when the levels are the highest) produced by the pituitary, urine free cortisol or their breakdown products (metabolites, esp. 17-hydroxycorticosteroids) and serum cortisol. If the serum cortisol level is low and the A.M. plasma ACTH is high (meaning that the pituitary is making enough ACTH to try to kick-stimulate the adrenal gland to make cortisol, but to no success) than the adrenal gland is weak and not producing sufficient amounts of cortisol establishing the diagnoses. 

d. Pituitary Insufficiency:
In this condition the anterior portion (front part) of the pituitary gland (once called the master gland "seat of the soul" by Rene Descartes) is failing to make adequate amounts of it's ACTH hormone which normally triggers and stimulates the adrenal gland to produce the life sustaining cortisol hormone. The symptoms are identical to Addison's above in that the same net result (low cortisol) has occurred, only this time the process is indirect (coined secondary hypocortisolism). Again we measure the same plasma ACTH and serum cortisol and urinary cortisol and metabolites. This time however a diagnosis is confirmed with both low (or almost normal levels) of serum cortisol levels are seen and very low levels of A.M. plasma ACTH are observed to due the poorly functioning pituitary gland. This condition may be more serious in that the pituitary (master) gland also makes many other stimulating hormones which trigger the target end endocrine glands as well (e.g. TSH stimulates the thyroid gland, ACTH stimulates the adrenal gland, FSH and LH stimulate the ovaries, testosterone stimulates the testis, Prolactin stimulates the breast and GH stimulates growth). Hence a poorly functioning pituitary will most likely have profound effects on these other glands as well revealed clinically to your examining physician (e.g. symptoms of hypothyroidism, growth failure, hypogonadism, breast discharge, infertility, abnormal periods, swelling, weight gain, skin discolorations and profound weakness to name a few). Investigation of a poorly functioning pituitary should be more elaborate often involving an MRI of the brain to rule out a mass lesion (tumor, benign adenoma or malignant) invading the pituitary.

e. Hyperparathyroidism:
We have 4 pea-sized parathyroid glands embedded within the ends of the bow-tied shaped thyroid gland. The parathyroid glands secrete PTH (parathyroid hormone) which regulates calcium metabolism. Hyperparathyroidism results high serum Calcium (hypercalcemia) causing this symptom. Fatigue is the most common presentation of this condition. Once again due to the many cellular processes requiring calcium there may be a multitude of symptoms, often vague and non-specific with this condition. Anorexia, excessive thirst (polydipsia), frequent urinating (polyuria), numbness and tingling about the mouth (peri-oral), itchiness (pruritus), poor concentration and easy fatigue are the earliest manifestations of this condition. Again this diagnoses is confirmed with blood tests, which would show both high serum calcium and high PTH levels indicative of this process.

5. Other Medical causes of Fatigue:

Now, Lisa, for completeness I must add the following list which again I'll only briefly talk about. Most of these topics will be dealt with individually on separate questions, which I am preparing.

a. Hepatitis
Other than fatigue, you really aren't describing the other associated symptoms of hepatitis. Characteristically, prodromal symptoms consist of 1 to 2 weeks of malaise, anorexia, nausea, vomiting, changes in senses of taste and smell, low-grade fever, right upper quadrant or mid-abdominal discomfort, and of course fatigue. I've discussed Hepatitis A in a previous question, and really want to reserve some more questions on the even more important Hepatitis B and Hepatitis C viruses. Very topical, very trendy, and whether they're sexy or not, I'll leave to your interpretation. If your doctor suspects any of these 'puppies' then he'll conduct the appropriate liver blood tests accordingly after your physical examination.

b. Mononucleosis (Infectious Mononucleosis)
Marked fatigue and swollen neck glands (cervical lymphadenopathy) are the hallmarks of this classic 'kissing disease.' The Epstein-Barr virus is the organism responsible for this sore throat. Prodromal symptoms of mononucleosis include malaise, headache, fever, sore throat, cervical lymphadenopathy and again fatigue. Treatment is largely supportive and symptomatic. Voice rest, humidification, and lozenges or hard candy provide some relief salt water gargling and aspirin or acetominophen also help. Must stay well hydrated with plenty of fluids.

c. Fibromyalgia
These often "moaner-groaners" will often tell me "Doc. I'm sore all over and haven't slept in 23 years!" Treatment is difficult and highly individualized with emphasis on active aerobic exercise, analgesics when indicated, possibly NSAIDS, possibly low dose antidepressants, and nutrition. Again, I will deal with this topic exclusively another time.

d. Substance Abuse
Lisa, I will be very disappointed if you've been 'sucking and blowing' you know what (crack, E , "shrooms" and the like) and are just giving me something to do. I will definitely address this very important topic in later dialogues.

e. Heart problem (CHF, MI, valvular heart dz)
Again this is for completeness. You're not mentioning chest pain, dyspnea, shortness of breath, reduced exercise capacity, swollen ankle, sleeping with 3 or more pillows up, dizziness or even loss of consciousness. However, I have seen youngsters such as you present with 'leaky' heart valves (valvular heart disease), or 'swollen-baggy' heart due to diseased heart muscle (cardiomypoathy), a weak heart which pumps poorly causing fluids to 'back-up' into the lungs (congestive heart failure with secondary pulmonary edema).  I even had a young chap present to my office complaining of fatigue to me while I was teaching a medical student and later discovered this guy was born with his heart on the right side of his chest (dextrocardia). Boy did I look smart that day. I of course missed this diagnoses and remain heart broken still.

f. Lung problem
If you're still reading Lisa, hopefully it's quietly; otherwise you'd be breathless by now. You're not a heavy smoker with any exposure to lung toxins such as asbestos, chronic flour or yeast or TB. In the elderly high-risk smokers they develop chronic obstructive lung disease, which certainly leads to persistent fatigue, as well as shortness of breath, cough and sputum.

g. Kidney problem
Chronic renal failure is tricky. It may present only with fatigue, but usually you look sick, with dry scaly skin, foul smelling urine (stranguria) and pale coloration. Often you have a history of recurrent urinary tract infections. This is really a lab diagnoses with weakened kidneys passing excess protein in the urine (proteinurea) and mild anemia.

h. Flu
True 'flu', as opposed to 'simple cold' consists of sudden onset of fever (over 38 C / 100 F), sore throat, body aches (myalgias), chills, headache, dry cough and of course fatigue. If you detect this early say within 72 hours there is new available antiviral medication. Check-out: www.flupill.com and see.

i. Cancer
I'm really stretching it now. You're not telling me anything about fevers, weight loss, swollen glands or chills and a battery of other symptoms to support this diagnoses. However, I have seen breast cancers, lymphomas (both Hodgkin's and Non-Hodkin's) and ovarian malignancies present in your age group. All of these ladies I might add had many other symptoms in addition to fatigue. 

j. Sleep Disorders
You mention no problem or change in your sleep pattern. Chronic insomnia from a variety of sleep disorders may certainly lead to persistent fatigue. 

k. Lupus (Systemic Lupus Erythematosus)
Lupus is Latin for wolf and the disease was named so, because of the characteristic resemblance of 'wolf-like' facial characteristics (facies) seen in the red cheek called malar flush in patients with this condition. Lupus usually occurs in young women, with a higher prevalence in blacks. It is characterized by joint pain and joint swelling, with a malar rash, anemia and other organ problems involving brain, lung and kidney. Specialized blood tests and perhaps biopsy are required to make this diagnoses.

l. Lyme Disease
A history of possible tick exposure, the typical Lyme rash (erythema chronicum migrans), and antibodies to Borrelia burgdorferi suggest the diagnosis of Lyme disease. This blood borne infection (spirochete) is amenable to therapy and cure with antibiotics. 

6. Chronic Fatigue Syndrome
Chronic fatigue syndrome (CFS) is really a diagnosis reached only after the above diagnoses have been excluded. CFS is a symptom-complex-illness characterized by prolonged, debilitating fatigue with many other nonspecific symptoms such as headaches, recurrent sore throats, muscle and joint pains, and cognitive complaints. Profound fatigue, the hallmark of the disorder, can come on suddenly or gradually and persists or recurs throughout the period of illness. Unlike the short-term disability of an acute infection, CFS symptoms by definition linger for at least 6 months and often for years. 

CFS affects mainly women between the ages 20 to 50 years old. The cause of this illness is unknown although there are many theories. I will discuss this syndrome at great length in an upcoming question. Successful therapy is aimed at managing the target problems on a symptomatic basis, which includes fatigue, sore muscles, sleep problems, cognitive impairments and psychologic symptoms. You don't sound like you have this condition, and for readers who are interested I promise to discuss this very controversial entity in an upcoming question, hopefully next month. However, it is fair to say that for therapy to be successful, you really do have to understand this syndrome and what is known about it as much as possible. 

B. PSYCHOLOGIC

What we're really talking about is the global epidemic of Depression and Anxiety. Fatigue is an important symptom of depression, often coexisting with early morning awakening, changes in appetite and multiple other non-specific bodily complaints. Persistent Anxiety may also result in generalized fatigue, due in part to difficulty in obtaining adequate physical and psychological rest. These are all too important topics to do justice in this context, but again I promise to discuss them in detail in subsequent questions. 

Lisa, you mention that your sleep, and appetite are OK, but what about your concentration, your cognitive faculties, and so on. If you or any reader is interested about these topics I recommend you check out the link section of this site under the "Mental Health Cites" and clicky-yah-yeah away to your hearts content.

C. PSYCHOSOCIAL

The 3 main culprits in order of importance: 1.stress 2. stress and 3. more stress. But what is stress? It's man-made and stems from fear. In order of what I see husband, work, money and in-laws (outlaws).

My first and most important advice, if you read anything in this essay. Do not rush to have children. You are young and have plenty of time. It might be humorous if you say, "Doctor I'm always exhausted and I'd like some birth control and some vitamins" and wait for a reaction. If you do, then e-mail me back the response. Live and experience yourselves. Seek first to learn who you are and who your partner is before you expand your burdens and responsibilities with children, house, mortgage, debt and so on. I have seen it happen time and time again with devastating far reaching consequences.

Lisa, why are you working so hard? For who and for what? Look at what it's costing you. Before you build a house on clay footings, build on your relationship; first with yourself and then with your partner. This will strengthen any future home and if desired family.

It's so easy to get caught up with all the greed, jealousy and self-serving interests these days. Blow it all away Lisa with a deep inner constant experience of love. Seek advice from someone you respect regarding past relationship closures, emotional baggage and personal toxins far exceeding any organic ones mentioned above. 

A word of caution about the "In-law-Outlaw" syndrome. Use discretion in what you choose to share with both your mother and in-law. Learn how to say much with few words and avoid gossip at all costs. Avoid loud and toxic persons, they are vexations to your inner harmony.

Enjoy intimacy with your partner. The pleasures of the body are important and beautiful, and should be enjoyed without shame or guilt. If you motivated, then these pleasures may expand with time to include higher 'peak moments' of the mind and soul as well. More about this on another question. 

SUMMARY

Well there you have it, Lisa. Your journey to health awareness is just beginning. Remember that you alone must define this journey as a joyful process, and that the true joy lays in the experience of the journey itself. What I mean is, that the joy is the journey and the journey is the joy. Clear?

Take care of your body. You asked about vitamins, I recommend starting with vitamin C 1000 mg daily taken with plenty of water (1-1.5 liters per day). Next, add folic acid (folate) at 5-10 mg daily with a good B complex multivitamin with nutrient supplement. Any additional iron should really be discussed with your doctor, pending your particular situation.

Eat sensibly. Your grandparents knew something regarding fresh fruits and vegetables. Learn the importance of organic foods and juicing. Intuitively, you know what to do, so do it! I will address this topic in detail in subsequent questions.

Exercise regularly. This is non-negotiable. Learn these habits now, while your still young, and mobile.

Relax your mind. You'd be amazed how rested you would feel after a good massage. Similarly you may wish to explore the benefits of deep breathing exercises and meditation.

Above all else: experience your soul and live life to it's fullest. Enjoy the now, this second, this moment. This will be the most difficult for you because it is the easiest. It begins with the process of defining yourself to yourself. Exactly who are you?

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