Ulcerative colitis and fatigue

Beyond Tired: Is Your Ulcerative Colitis Causing Fatigue?


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Before Abby Bales had surgery for ulcerative colitis, she couldn’t make it through the day without a nap. But Bales was more than just tired — she was experiencing fatigue, a common symptom of ulcerative colitis that drains energy and causes an overwhelming sense of exhaustion.

“When I was flaring, and for the last year before surgery, the fatigue was absolutely unreal,” says Bales, a doctor of physical therapy in New York City and author of the blog Run Stronger Every Day. “I required a nap in the middle of the day just to make it to the end of the day.”

Like Bales, nearly 75 percent of people with an inflammatory bowel disease (IBD) such as ulcerative colitis experience fatigue when their condition is flaring, according to a study published in 2011 in the journal Inflammatory Bowel Diseases. What’s more, 30 percent of the people in this study who were in remission — meaning that they weren’t experiencing other symptoms of ulcerative colitis — also qualified as having fatigue.

“Fatigue is not a universal symptom of ulcerative colitis, but it’s a common one,” says William Katkov, MD, a gastroenterologist at Providence Saint John’s Health Center in Santa Monica, California. “The important point is that fatigue should be addressed by both the patient and the treating physician.”

If you’re living with ulcerative colitis and you’re experiencing fatigue, it may feel as if you’ll never get your energy back. But by tightening control of your condition and making some healthy lifestyle changes, you can manage your fatigue. Start here.

What Fatigue Feels Like

Fatigue is beyond just a passing feeling of being tired, explains Dr. Katkov. “People with ulcerative colitis can experience malaise, a profound kind of fatigue that makes it difficult to carry out normal activities.”

Tina Haupert, who was diagnosed with ulcerative colitis in 2011, agrees. “I’m pretty much always tired,” she says. “But I do my best to eat well and exercise, which seems to help.”

One of the most frustrating aspects of ulcerative colitis fatigue is its unpredictable nature. From 2010 to 2014, the British organization Crohn’s and Colitis UK assessed more than 500 people with IBDs to learn more about their fatigue. Many participants complained that it would come on suddenly, without warning, and vary from day to day. They also said that this type of fatigue — which they described with the terms “brain fog,” “completely wiped out,” and “zombie mode” — had a negative effect on their quality of life. It affected their memory and concentration, made it harder for them to exercise or attend social activities, and interfered with their relationships and ability to work. And it often took a hefty emotional toll, lowering their confidence or leading to depression.

Ensuring that fatigue doesn’t interfere with the quality of life, the ability to work, and the capacity to have a normal social life is central to the goal of treating a chronic condition like ulcerative colitis, Katkov notes. “We don’t want to settle for a lower quality of life than what can be achieved with aggressive treatment,” he says.

What Causes Ulcerative Colitis Fatigue?

While people with ulcerative colitis may experience fatigue for a number of reasons, it may simply be caused by the body’s response to inflammation in the colon, says Katkov.

In addition, fatigue is sometimes related to anemia, which is a common complication of ulcerative colitis, caused by blood loss, diarrhea, and malabsorption of nutrients. Other possible triggers include certain medications, inadequate sleep, being overweight or underweight, and pain, according to the findings of the Crohn’s and Colitis UK study.

And don’t rule out the emotions. “With any patient — but especially someone with a chronic disease,” Katkov says, “you want to consider their emotional life, stress, and depression.”

9 Tips for Managing Your Fatigue

The key to easing fatigue is not to ignore it. “Fatigue is a sign that something requires attention,” Katkov says. Consider the following steps.

Get ulcerative colitis under control with treatment. Since fatigue is often related to the symptoms and inflammation of ulcerative colitis, it’s more prevalent when the disease is active. “When ulcerative colitis is well controlled, a patient is not expected to have fatigue,” Katkov says. Work with your doctor to find the best treatment approach for your condition.

Rule out other causes of fatigue. “Go through the full list of diagnostic possibilities,” Katkov says. For example, if your ulcerative colitis is in remission and you’re still experiencing fatigue, have your healthcare provider run a blood test to check for anemia or vitamin deficiencies. Or ask your doctor whether a medication or a recent stressful situation might be triggering your tiredness. Says Katkov, “Get to the root of the problem and address it.”

Move more. It may seem counterintuitive, but exercise has been shown to have a positive effect on fatigue in people with ulcerative colitis, according to a 2014 review of research in BioMed Research International. Haupert, who’s a self-proclaimed fitness “nut” and the author of the blog Carrots ‘N’ Cake, suggests that you try to do something active every day — “even if it’s a short walk around your neighborhood. Even though I battle fatigue, I always feel better and more energized after some exercise.”

Try to sleep eight hours a night. “A growing body of evidence suggests that disordered or inadequate sleep can significantly impact health,” says Katkov. “And fatigue is central to that.” As a rule of thumb, the National Sleep Foundation recommends that adults get seven to nine hours of sleep each night. If tossing and turning at night is leaving you feeling fatigued the next day, talk to your doctor about ways to improve your sleep. Also, consider cutting back on caffeine and removing distracting electronic gadgets from your bedroom.

Eat your vitamins. There’s no cure-all diet for ulcerative colitis or fatigue, but eating well certainly plays a role in overall health, says Katkov, who suggests that you educate yourself about a healthy, balanced diet that’s rich in a range of vitamins.

Plan ahead. Got a big event on the calendar? “Make sure you have time to rest before and after,” Bales says. “Stress and lack of sleep don’t do anything good for your immune system.”

Rethink the 9-to-5 day. “When fatigue is significant, adjustments in work are appropriate and recommended,” Katkov says. If fatigue is hindering your ability to get through the workday, consider asking your employer whether he or she would allow you to work more flexible hours.

Try to reduce stress. Practice relaxation techniques (for example, yoga, tai chi, and deep breathing), and you may find the benefits to be twofold. According to a review of research in Gastroenterology Research and Practice, easing your level of tension may lower your risk of an ulcerative colitis flare — and reducing stress may also help lessen fatigue.

Learn your fatigue triggers. Everyone’s different, so try to figure out which habits wear you out and which tend to put a little pep in your step — and act on them accordingly. “Manage your life in a way that works for you,” Bales recommends. “If that means you work out in the morning and go to bed early in the evening, that’s the way you need to do it.”

Dealing with Fatigue

It’s 2 o’clock in the afternoon and your day has been like any other – working, studying, meeting friends, spending time with your family – when that all-too-familiar wave of exhaustion washes over you. Perhaps you could feel it coming, or perhaps it hits you out of the blue. Either way, any plans you had for the rest of the day are well and truly off the table.

Fatigue is one of the most common symptoms experienced by people with Inflammatory Bowel Disease, with around three quarters of IBD patients experiencing fatigue during a flare-up. For some, that fatigue is a constant companion even in between flares – it is a brick wall that can rise up at any time.

Complications such as anaemia, poor sleep due to medication, or pain levels can also contribute to feelings of exhaustion.

Finding ways to manage fatigue can be a useful tool for Crohn’s and colitis patients, to ensure that the impact of sudden changes in plans due to flagging energy is limited as much as possible.


  • Keep a close eye on those blood tests
    Checking on iron levels, vitamin B12 and other chemical or nutrient deficiencies can help your treatment team to find the right mix of medication for you. Adding iron supplements or reducing the dosage of a medication can make a world of difference to energy levels for some people.
  • Focus on keeping fit
    While being careful not to overstress yourself, try gradually increasing the amount of physical activity you do. Make use of a gym membership, walk rather than catching the bus for shorter trips, or commit to a team sport. Improving your overall fitness can ensure your energy stores are higher, potentially reducing the impact of those fatigue-ridden days.

  • Assess your diet
    Do you have any foods that make you feel heavier, or sluggish? Complex carbohydrates such as cereals or porridge can provide you with energy over a longer time frame, while simple carbohydrates (those cakes, biscuits and other sugary treats we are all fond of) will give you a short burst of energy, often followed by a ‘low’. Consider if you are getting a good mix of fruits and vegetables, carbohydrates for energy, and rich protein.
  • Manage your workload
    Wherever possible, ensure your workplace, family or education provider is aware of your condition and see what flexibility is available with responsibilities, work hours and prior planning. For example, taking the afternoon off following a doctor’s appointment may be a welcome break to rest, recover and prepare for the next week.
  • Know your body
    You are the best person to assess when you need to rest or recharge. If you need a break halfway through the morning, or in the early afternoon, find a way to make time for this. Get a good night’s sleep whenever possible, explore restorative therapies such as yoga or remedial massage if they work for you, and make your health a priority not only in times of flares, but every day. Building good habits during your good days can make the bad ones just that little bit easier down the line.

And if all else fails? A cup of coffee, a hug from a loved one, or a couple of episodes of your favourite television show can sometimes make all the difference.

Back to Our Blog


Fatigue has been called the most under-managed problem for people with inflammatory bowel disease (IBD).1 Fatigue is the second most common symptom of Crohn’s disease, and fatigue is reported by approximately a third of people with ulcerative colitis.2 It affects most people with active IBD, as well as many people in remission.

Fatigue is an ongoing and overwhelming sense of tiredness, weakness, or exhaustion. It interferes with your ability to do physical or mental work. Getting enough sleep or rest does not cure fatigue.3

Some studies show that fatigue is more bothersome than bowel symptoms.3 Fatigue can decrease your quality of life and increase disability.3,4 It can affect your job, family life, social activities, and emotions.

What causes fatigue in people with Crohn’s or UC?

Several factors contribute to fatigue in inflammatory bowel disease:

Difficulty sleeping

People with inactive IBD report having a harder time falling asleep and staying asleep than healthy controls.5 In one survey, 71% of respondents reported waking up during the night, usually due to diarrhea or abdominal pain.5 As a result, they had less daytime energy and increased tiredness. They were more likely to use sleeping pills. About 24% of people with Crohn’s disease and 15% of people with ulcerative colitis have night sweats or fever that can disrupt sleep.2

About 60% to 80% of people with inflammatory bowel disease are iron deficient. One-third are anemic.6 Anemia is a condition in which your blood does not carry enough oxygen throughout your body. You may feel low on energy. This limits your ability to participate in normal activities. Another symptom of iron-deficiency anemia is restless legs syndrome, which can disrupt sleep.6

Medication side effects

Fatigue is a side effect of methotrexate and azathioprine.3


Difficulty sleeping and fatigue are overlapping symptoms of IBD and depression.3 About a quarter of people with Crohn’s disease are depressed.7 Depression also is seen more often in people with ulcerative colitis compared to people without IBD.8 The overlap between depression and IBD may play a role in feelings of fatigue even during periods of remission.


Fatigue is a common symptom of many chronic inflammatory diseases. For example, it is well known in rheumatoid arthritis, lupus, and ankylosing spondylitis (a spinal disorder). Researchers have studied animals injected with inflammatory signaling chemicals. The animals become tired and less functional.3

How common is fatigue in inflammatory bowel disease?

Fatigue affects many people with IBD, and it occurs more frequently among people with Crohn’s disease. Approximately 54% of people with Crohn’s disease and 33% of those with ulcerative colitis report experiencing fatigue.2 Fatigue also seems to worsen with more aggressive disease, with the people with the most aggressive Crohn’s disease most likely to report fatigue.9 Up to 86% report feeling fatigue during moderate-to-severely active Crohn’s disease.3 Even during remission, about 40% to 50% of patients with IBD disease report fatigue.3,9

How is fatigue evaluated?

Many different scales and questionnaires are used to measure fatigue. No single standard exists.3 One questionnaire about fatigue with inflammatory bowel disease was developed and scientifically validated in the United Kingdom and is available online. You or your provider may be interested in using this questionnaire to track changes over time.1

Your health care provider may do laboratory tests. It is common to check for anemia, active inflammation, thyroid function, or pregnancy.10 Your provider may ask questions about sleep hygiene, medications, and exercise.

How is fatigue treated?

Some people feel less fatigue once they start treatment for Crohn’s disease.3 In other inflammatory conditions, biologic medications reduce fatigue.3 One theory is that the intestinal lining needs to heal for the fatigue to improve. People in remission from symptoms often still have inflammation in the digestive tract.

If you have iron-deficiency anemia, your health care provider probably will recommend an iron supplement. Iron supplements can be taken by mouth or intravenously. Iron supplements may not be enough for severe anemia. Your provider may prescribe an erythropoiesis-stimulating agent.6 These medications cause your bone marrow to make more red blood cells.

If you are taking medications that cause fatigue, it may be possible to switch.11

You may find some general recommendations for fatigue helpful.10 Perhaps surprisingly, moderate exercise can be better than rest. An example of moderate exercise is 30 minutes of walking. Doing your best to maintain your relationships with friends and family may help with fatigue. You may find that returning to work—particularly if you can have flexible hours—can be energizing. Of course, if your IBD is very severe, these activities may be difficult or impossible, which can be very frustrating.

Extra hours of sleep may not make you feel more rested. However, improving the quality of sleep you get might. Tips for improving sleep quality include:10,12

  • Avoid caffeine, nicotine, chocolate, and alcohol before bed.
  • Increase your exposure to natural, bright light during the day.
  • Exercise early in the day.
  • Limit naps to less than 1 hour in the early afternoon.
  • Eat your last meal several hours before bed.
  • Make sure that your sleep environment and bedtime routine are pleasant and relaxing.
  • Limit noise, television, and other screens before bed.
  • Keep extra pajamas and a fresh pillowcase nearby and sleep on a towel, if night sweats are a problem.

Can my ulcerative colitis cause extreme fatigue?

Ulcerative colitis can cause fatigue through several factors. Ulcerative colitis causes ulcers in the intestine which can bleed and cause the person to become anemic. Anemia can cause fatigue because of a lack of red blood cells which produce oxygen. Less oxygen means the body has to work harder to keep up with the same amount of work it used to do with normal oxygen. Ulcerative colitis can also cause nausea and decreased appetite, which can both lead to fatigue because the body isn’t getting enough nutrients to fuel itself. Finally, patients with ulcerative colitis can be fatigued because of a lack of absorption vitamin B12 which is an essential nutrient in the formation of healthy red blood cells. Coupled with anemia, vitamin B12 deficiency can cause extreme fatigue. Treatment of fatigue in ulcerative colitis patients includes reducing ulcerative colitis flares (to reduce blood loss), and taking vitamin B12 shots if the patient is vitamin B12 deficient. Contact one of our doctors for more information.

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