The following micronutrients can contribute to depleted energy levels commonly experienced with IBD. A good way to advocate for yourself if you keep normalizing exhaustion even after sleeping sufficiently and staying hydrated is to ask your doctor to regularly check your labs. 

Note: Vitamin supplementation should only occur to correct lab patterns of deficiencies/insufficiencies and be dosed by your doctor or registered dietitian nutritionist according to your individualized needs. Supplementing when it is not medically needed could cause negative health effects. This article is not meant to replace the advice of your licensed healthcare professional or be prescriptive. 

1. Iron

Should we start with the most obvious? Studies have shown that 60%-80% of patients with inflammatory bowel disease (IBD) will have an iron deficiency, even in remission. Anemia is the most common complication of IBD that happens outside of the GI tract (1). Anemia is a more severe form of a deficiency that results when there is a decrease in red blood cells or hemoglobin available to transport oxygen throughout the body, which can result in fatigue and the feeling of light-headedness. However, over ⅓ of patients with iron-deficiency do not experience any symptoms at all (2). 

Ask your doctor for an “iron panel” to check your iron status:

• Every 6-12 months with mild disease or remission
• Every 3 months with active disease (3)

Please do not supplement iron without your doctor's supervision, because it can cause other copper abnormalities that can interfere with heart function (4). Taking copper preventatively should be avoided as it can lead to liver damage and exacerbate GI symptoms, such as diarrhea (5).

2. Thiamine, or Vitamin B1

Even in patients in remission, fatigue can still be commonly experienced in IBD. Some research has shown that thiamine supplementation under the supervision of a medical team has statistically significantly reduced fatigue even in patients in disease remission (6, 7). 

Currently there are no established recommendations for how frequently thiamine should be monitored. Individualized supplementation and monitoring protocol can be established with your trusted GI care team.‍

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3. Vitamin B12

Vitamin B12 is responsible primarily for maintaining a healthy shape of the red blood cells and producing enough red blood cell. A B12 deficiency can occur based on the location of active disease, or because of the inflammatory process of IBD. B12 supplementation should occur as soon as a deficiency is identified. Intramuscular injections may be most effective, especially in post-surgical patients with Crohn’s disease. (8)‍

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4. Folate

Folate is responsible for cell growth and function. In pregnancy, folate is necessary for healthy fetal growth and development. A folate deficiency can occur from malabsorption, or as a result of methotrexate which is often why your team may be frequently monitoring this lab if you are on methotrexate or sulfasalazine (9). If you are on a prenatal vitamin with folate, speak with your care team to ensure that the supplement contains adequate amounts of folate (8). 

The European Crohn’s and Colitis Foundation recommends checking Folate and B12 levels at least annually (3).

What if all these labs are normal…and you’re still exhausted?

• The inflammatory process of IBD demands more energy and calories, which can sometimes lead to the feeling of fatigue and disinterest in food (10). Ensure you are vigilant about eating enough to support your body, especially if you do have active disease! If this feels overwhelming, do not hesitate to reach out for support from an experienced IBD registered dietitian.
• Over 50% of patients with or without active disease report sleep disturbances and difficulty sleeping (11). Ask your doctor about getting a sleep study done if you feel like you could benefit!
• Dehydration is a common contributing factor to fatigue (12). Remember to stay vigilant about hydration. This post touches on hydration tips for physical activity with IBD. 

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References

1. Gisbert JP, Gomollon F. Common misconceptions in the diagnosis and management of anemia in inflammatory bowel disease. Am J Gastroenterol. 2008;103:1299–1307.
2. Coyer S. M. (2005). Anemia: diagnosis and management. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners, 19(6), 380–385. https://doi.org/10.1016/j.pedhc.2005.07.014
3. Dignass, A. U., Gasche, C., Bettenworth, D., Birgegård, G., Danese, S., Gisbert, J. P., Gomollon, F., Iqbal, T., Katsanos, K., Koutroubakis, I., Magro, F., Savoye, G., Stein, J., Vavricka, S., & European Crohn’s and Colitis Organisation [ECCO] (2015). European consensus on the diagnosis and management of iron deficiency and anaemia in inflammatory bowel diseases. Journal of Crohn's & colitis, 9(3), 211–222. https://doi.org/10.1093/ecco-jcc/jju009
4. Ha, J. H., Doguer, C., Wang, X., Flores, S. R., & Collins, J. F. (2016). High-Iron Consumption Impairs Growth and Causes Copper-Deficiency Anemia in Weanling Sprague-Dawley Rats. PloS one, 11(8), e0161033. https://doi.org/10.1371/journal.pone.0161033
5. Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. Washington, DC: National Academy Press; 1998.
6. Bager, P., Hvas, C. L., Rud, C. L., & Dahlerup, J. F. (2021). Randomised clinical trial: high-dose oral thiamine versus placebo for chronic fatigue in patients with quiescent inflammatory bowel disease. Alimentary pharmacology & therapeutics, 53(1), 79–86. https://doi.org/10.1111/apt.16166
7. Costantini, A., & Pala, M. I. (2013). Thiamine and fatigue in inflammatory bowel diseases: an open-label pilot study. Journal of alternative and complementary medicine (New York, N.Y.), 19(8), 704–708. https://doi.org/10.1089/acm.2011.0840
8. Eiden KA. Nutritional consideration in inflammatory bowel disease. Pract Gastroenterol. 2003;27:33–54.
9. Gasche, C., Lomer, M. C., Cavill, I., & Weiss, G. (2004). Iron, anaemia, and inflammatory bowel diseases. Gut, 53(8), 1190–1197. https://doi.org/10.1136/gut.2003.035758
10. Lucendo AJ, De Rezende LC. Importance of nutrition in inflammatory bowel disease. World J Gastroenterol. 2009;15(17):2081–2088.
11. Graff LA, Clara I, Walker JR, et al. Changes in fatigue over 2 years are associated with activity of inflammatory bowel disease and psychological factors. Clin Gastroenterol Hepatol. 2013;11(9):1140–1146.‍
12. Shaheen, N. A., Alqahtani, A. A., Assiri, H., Alkhodair, R., & Hussein, M. A. (2018). Public knowledge of dehydration and fluid intake practices: variation by participants' characteristics. BMC public health, 18(1), 1346. https://doi.org/10.1186/s12889-018-6252-5

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