Epistemic status: This post leans heavily on my personal experience and is not well-researched. I’m not a doctor, nor have I studied medicine. I do consider myself pretty good at Googling things though. Also, a real doctor did look over and at least tacitly approve of this post. I’m not doing much in the way of literature review, validating claims, etc so take everything with a teaspoon of salt. There are also more side effects and bad interactions than I’m able to mention. Do your own research before you try any interventions I suggest! Also, if you find something definitely wrong in the post let me know in the comments and I’ll try to correct it.

Over the past two years or so I’ve been on a long journey to figure out why I often have joint pain (gradually expanding to almost all my joints), gut problems, and episodes of extreme fatigue about once a week. When I say extreme fatigue try to imagine the following: moving sucks and you don’t want to do it, same with thinking about things, and lying on the floor for half an hour because you slid off your chair seems like a reasonable thing to do.

I am not totally sure I’m at the end of this journey but I’ve learned enough to say things which will probably be useful for some people. I was really surprised by a lot of what I found and I expect many of you will be too. I’m also really surprised by the lack of something like this piece out in the world as this is so clearly a thing many people struggle with (if it already exists please post a link in the comments!).

The main things I have looked at are food sensitivities, stress, irritable bowel syndrome (IBS), and gut health. There are obviously a ton of reasons why you could be fatigued (or have other hard-to-diagnose health issues). To demonstrate how hard this is, this is why we have catch-all diagnoses like fibromyalgia and chronic fatigue which nobody really knows what to do with. They just represent some bundle of symptoms with no clear underlying cause (and people have really been trying to find a cause!). Fatigue is a symptom of tons of major illnesses. Suffice to say this is super difficult and I’m just covering a few possibilities. Also, obligatory disclaimer: this is not medical advice.

Why is this important?

My guess is that a bunch of you, maybe most, are not at or near optimal health. This might be a not-knowing-what-the-world-should-look-like-before-you-try-on-glasses kind of thing. You might not realize just how much energy you could have. For example, you probably don’t need to be tired for the first hour or two after you wake up! It’s possible to wake up and feel great most of the time (I’m pretty sure...). Of course sleep, exercise, and nutrition are the obvious things to do and you should almost certainly try those first.^[1] There are also good guides on those already (and I see them discussed often in EA circles) [edit: Good sleep guide from Lynette Bye]. If you’re still having problems after that though you probably don’t need to keep having those problems. And if you can solve those problems now the expected value is generally extraordinary. If you get a 1% energy gain consistently through your lifetime because of something you find out now, that is super valuable. Like more valuable than almost anything else you could possibly do for your productivity. If you already have health issues then probably you’re going to get a whole lot more than a 1% energy gain (I’d estimate a 20-100% gain for me if I can solve my issue. This could lead to a much higher boost in impact over the long-term^[2]). That’s going to matter a whole lot more than whether you use ultraworking or focusmate, what note-taking software you use, etc etc. Seriously, if you have health problems you should really focus on those first before you worry about minor changes to productivity habits (unless of course you're fairly sure your health problems are intractable).

Over these years of having low energy I might have become a little biased towards thinking energy is important but it does seem clear it’s a factor in success which probably doesn’t quite rival intelligence but is definitely up there in the pantheon of ideal traits. Elon Musk, Dr. Oz, and Jeff Bezos are famously super energetic people (among other things) and I’m guessing that most very important figures tend to have a lot of energy (though I have nothing to back that up, just a bunch of anecdotes and experiential evidence). So there might even be something like increasing returns to energy levels? I don’t know. I could wax rhapsodic about how important energy is, how it improves rationality, IQ, or charisma but suffice to say energy seems incredibly important and if you can do something to improve it in the long term, that’s worth spending a lot of time, money, and energy on.

If you’re like me you probably went to the doctor once or twice to ask about your health problems and they either prescribed you something to patch over the symptoms and shrugged and/or said, “I don’t know what it is but it’s not going to kill you”. Then you thought, ‘doctors are smart so if they don’t know what it is there’s no way I’ll figure out what it is’. Boy do I have news for you. Doctors are not so smart and not so helpful for the most part (sorry doctors). They don’t seem to think of things that aren’t actual diseases. Stress, gut health, food sensitivity, etc. are not things they’re going to suggest for the most part. In general they are looking for problems which are very bad, they can test for, or which have some clear diagnosis. If they don’t find those after a cursory look then for the most part that’s it. I remember going to one doctor three different times with bad constipation and asking what I could do about it. She just prescribed me the same thing each time and didn’t mention anything about how diet could help or probiotics or anything like that. And I even asked what I could do to address the problem long-term! And there’s such good evidence for several interventions!

Potential contributors to your problems

Stress

If you’re like me you’ll look at this section and think, “I’m not that stressed. I’ve seen other people who seem to do a lot more work than I do and they seem fine so stress is not the problem”. You’ll think “I’m someone who knows how to deal with their emotions and I’m smart about this and if I were stressed I would definitely know it”. And you’d hear your friends say “you don’t seem like a very stressed person”. And your day-to-day experience doesn’t look like what stressed people look like in movies. Perhaps a doctor will have asked you whether your problems might be caused by stress and were able to confidently dispel their argument. So you’ll be pretty sure you’re not stressed.

But, maybe you actually are stressed!

I just started taking this hypothesis seriously after ~2 years of suffering from on-off fatigue and joint pain. Somehow taking a week off and meditating a bunch (I can definitely recommend Loch Kelly’s course on the Waking Up app by the way) fixed most of my joint pain and maybe most of my fatigue (for now at least). So I’m really thinking now that stress is the thing. And once I started looking back through this lens it became increasingly obvious that this was a super important candidate. It’s also very common. Some statistics say that 75 to 90% of all cases which doctors see are stress-related in nature. Now I don’t know how that was calculated or if it’s true but suffice to say stress is a super obvious cause for fatigue and other vague health issues (and certainly exacerbates most things, including all the other problems I list). It’s also something which different people will have wildly different tolerance levels and reactions to (so someone might be more stressed than you but be fine while you might get stressed and then develop, say, pain in all of your joints and bouts of extreme fatigue).

I really liked this 80,000 hours post from 2016. In particular, they have a table which shows how your job might be causing stress.

I highly suggest going through this table one by one and considering how much this fits your job description. You might also compare your symptoms with those of chronic stress (but recognize the possibilities are much larger than just the list of common symptoms). You might reflect on past periods and see whether stress level correlated with energy levels (probably with a lag by the way). For example, do you generally feel way better after vacations or just a bit better? You might also look back and try to figure out whether your problems tend to be more intense later in the week rather than in the beginning after you’ve had some rest on the weekend.

Another possible indicator of chronic stress (or something else) is if you tend toward, for example, the following behaviours: You move from distraction to distraction throughout the day without ever taking time to sit with your thoughts or fully relax (no, Netflix is not fully relaxing!) + bonus points if you actively avoid being alone with your thoughts; you sometimes get upset to a measure above and beyond the degree warranted by the situation (e.g. a computer bug makes you want to throw something across the room); you often finish work feeling totally exhausted, like you've used up every ounce of energy for the day.

Note also that your symptoms from chronic stress might not take on an intense and obvious form but could just make you a bit worse at thinking, have a bit less energy, less patience, etc. Basically, even if it's not a huge problem it's probably worth looking into (especially as it might eventually become a huge problem).

Food sensitivity

It’s relatively likely that you have some kind of food sensitivity. Something between 0.5-6% percent of people have gluten intolerance and 68% percentof people have lactose intolerance (though less so in western countries). Maybe something like 15% of people have a food intolerance (emphasis on maybe, I didn’t read the study and I’m not sure I trust it^[3]). The point is, food intolerance is probably more common than you think. They also cause all kinds of weird symptoms which you might not expect. They’re not like food allergies which are sudden and pretty obvious, they might come after an hour or two or maybe a day and cause vague weird symptoms like fatigue, depression, joint pain, arm numbness, nasal polyps, etc.

Food sensitivities are definitely worth looking into if you have fatigue or other odd health problems. But they can be an absolute pain in the ass to figure out. You can get some tests done by doctors but for the most part you have to do this the old-fashioned way. You just stop eating things for a while and see if things get better and then eat them again and see if things get worse. The really frustrating thing about this method is that you might have more than one food sensitivity. If that’s the case then cutting just one out won’t really tell you anything. You’ll still feel like crap. To make it even more complicated, cutting out food you're sensitive to can make you feel worse for awhile before you get better! That’s why elimination diets are often recommended where you cut out everything which might be a problem for a few weeks (though it’s impossible to cut out everything of course so you might have to try multiple elimination diets). This sucks because it takes a lot of time and doing these elimination diets is, again, a pain in the ass. There are some tests you can do but from what I understand they’re not very reliable. They still might be worth trying though.

Nutritional deficiency

I haven’t really looked into this but it seems worth mentioning. Nutritional deficiencies cause all kinds of weird problems so they could be responsible for most problems you have. This is especially the case if you’re vegetarian or vegan^[4]. You can mostly get tests for nutritional deficiencies but you might have to poke your doctor to get a broad range of things tested. When I did this I just got tested for iron and B12 because I said I was vegan. If you’re going to do it you should spend the extra money (if you have it) and just get lots of things tested. Taking a multivitamin is a very cheap but much less accurate and good test of this (it’s probably worth spending a few extra bucks for the good stuff by the way).

Gut health

This is a pretty big and new one. Just in the past decade this has caught on and we’re finding that gut health is associated with tons of stuff. Like depression, fatigue, diabetes, arthritis… Most things apparently. Most people probably don’t have great gut health? We don’t really know. We're still figuring out how to measure whether people have good gut health and how to intervene. Luckily it’s pretty easy to give this a trial run. If you want to try it then probably what you want to do is eat a bunch of prebiotic and probiotic foods for two weeks or a month and see what happens. The alternative is to take prebiotic and probiotic pills, which is even easier. This is one of those things where you might as well test it even if you’re pretty healthy, it might just help and then you just bumped your energy levels up and you can do so continuously for cheap with zero downsides.

Irritable Bowel Syndrome

If you’re like most of the US population then you're 30% likely to have IBS. That’s a pretty high probability! If you have stomach pain, bloating, diarrhea, constipation, or some kind of gut issues then you might fall under this very large umbrella of IBS. That’s kind of it, there’s not that much you can do to diagnose it [update: there are apparently things you can do to diagnose it] (though it’s worth noting it could be a bunch of other bad things which you should try to rule out first, like inflammatory bowel disease (IBD), which is much worse). But this is related to a bunch of other problems like depression and fatigue. Lots of stuff. So while bloating may not be so bad on occasion, fixing your IBS might help fix a bunch of other problems. While we still seem to be pretty bad at treating this, we are getting a lot better. Probiotics seem to work for some people. Stress reduction seems to help. The FODMAP diet seems to help. And then there’s this crazy thing which actually has good evidence behind it called gut hypnotherapy. They do a kind of guided meditation where you just kind of do “healing” on your gut and relax it and then it helps somehow. Like it seems to help a lot. There are a bunch of guided sessions of this on YouTube for free so those are probably worth trying and would be pretty cheap to trial for a week or two (though I have no idea how they stack up against in-person therapy. Probably not too well).

Mental health more generally

Last but not least (just the one I have the least experience with, so take this advice with extra salt^[5]), if you have a mental health issue, get a therapist (even if it doesn’t seem that bad). Having mental health problems sucks, will be a big drain on productivity, and will exacerbate any other problem you have. I don’t have personal experience with this (though maybe I should…) but I’ve heard from credible sources that the ideal thing is to have a therapist you trust before your mental health gets too bad. This is another one of those things where you can avoid potentially enormous suffering by paying money and putting in the effort before things get really bad.

You might have a diagnosable mental health issue and not know it. Take some quick tests online for depression, anxiety disorders, ADD, etc etc. This will take like 10 minutes each and maybe you’ll find out you have some issue which you can fix by taking drugs or doing therapy. It’s worth doing this even if you think the probability is pretty low. You should not take the results super seriously if the probability seems low to start with though. Just take it as an indicator to look into it more. Maybe you’ll get to take Adderall all the time, who knows!

What to do in general

Spend lots of money and time on it! It’s definitely worth it! But maybe you don’t need to. There are a bunch of cheap interventions you can try first. Just don’t get your hopes up on any given one. Take a portfolio approach and keep it diverse (and low-risk).

One thing people sometimes say when I tell them there is a small chance taking some pill will fix their problems is that this seems somehow like cheating because it doesn’t require any lifestyle changes. As if because it’s easy you don’t really deserve to have it fixed? I don’t get it but suffice to say that if for ~$20 you can trial something with a simply massive expected value (even if it’s unlikely to work) and usually with almost no downside (you can just stop taking it after two weeks if it doesn’t work) you should definitely try that thing. Think of it like buying a lottery ticket but with much better odds and a chance of actually making you consistently happier in the long-run.

Keep in mind you don’t necessarily need to do one intervention at a time to judge what works for you. It can be better to layer a few on top of each other as 1) there might be complementary effects^[6] 2) you get an answer faster 3) if it works then you can drop one intervention off at a time and see what worked. Just try to document things well so you can tell what worked and what didn’t (e.g. at least track mood, energy, productivity, and which interventions you’re trying. Do so consistently).

The cheapest, easiest, and lowest downside interventions to try (in rough order of easiness and effectiveness)^[7]:

• Take a multivitamin (and/or read up on nutrition and improve your diet and/or get a blood test for important nutrients)

• Try some probiotics and prebiotics. Try a few strategies (e.g. pills, food, other pills) on this because nobody knows how to do this well. Try each method for at least two weeks and see what happens. [update: some evidence (which I haven't looked at yet) points to these not working well. I still think it's worth giving it a go]

• Taking a de-stressing break. Take a week or two off work and see if your symptoms clear up. Really try to de-stress though. If you lie on the beach but you’re constantly thinking about work or your symptoms, that doesn’t count as de-stressing. This is also not a break where you just ‘work lightly’ or catch up on a side project (says the guy writing this post on vacation). Take a real break! Forget about work for awhile

  • Note that if you’re very stressed you may just get more tired and worse when you take a vacation. This might be something like your body catching up on fixing itself. For this reason it might be best to take two weeks off and expect the first week/few days to be low-energy.
    • Follow-up note: If you are not able to run this test despite taking time off because you can’t stop being stressed or can’t stop working, stress is almost certainly your problem and you should almost certainly try really hard to fix it (like you should move to Nepal for a month and go on retreat or something. Not really. But kind of).
  • If this works you need to re-think how you’re going about work and try to figure out how to make your work less stressful. I found this article very useful. Depending on your supervisor this might be more tractable than you think. There are also loads of non-work interventions to try (maybe I'll write about those another time).

• Try to fix your mental health issues and/or figure out whether you have one by doing some mental health questionnaires for various mental health issues. Depending on results see a therapist to reassess and start working to fix the thing.

• If there are any foods you’re suspicious of having a sensitivity to then stop eating them for three weeks and then try to reintroduce them. See what happens. Log your energy levels, what you ate, and symptoms throughout the process.

  • If this doesn’t work but food sensitivity still seems like a potential problem then it’s probably worth seeing a dietician. It’s not a super hard thing to figure out but it’s super hard to actually keep the motivation, not mess it up (e.g. it’s really hard to figure out what has gluten. Did you know oatmeal sometimes has it?), not trick yourself into thinking, ‘I know they say 3 weeks but if I just try it for a week it’ll be fine right?’), etc. This is especially the case because most of the information on food sensitivity online is very low-quality.
  • It might be worth getting a food sensitivity test as well, just don’t trust the results too much.

• Get a better doctor, try a few different ones, or otherwise take responsibility for your own health rather than expecting doctors to figure out your health issues for you.

  • This one is much more costly to do but it can really be worth it if nothing else is working! Again, fixing your health should generally be priority #1 if you’re not in ship-shape.
  • When you see a doctor don’t expect them to solve things for you or even to attain a comprehensive list of all your symptoms. As you become more well-versed with your condition (but only then!) you should move toward treating them more as a useful encyclopedia of medical knowledge and giver of medicine rather than an all-knowing problem solver.^[8] I.e. more of a tool AI than an oracle AI (look, now it’s AI governance!). To illustrate, most times I’ve been to the doctor I’ve started to list things then been interrupted and never got back to listing them! Being the agreeable person I am, I just let this slide. What I found helpful was to create a document with my health history and symptoms which I can give directly to the doctor. That’s much easier than trying to remember everything on the spot (especially if you have embarrassing symptoms). In short, there’s a skill to being a patient and you may actually have to get good at it to benefit from the medical system.

• Try a gut hypnotherapist. I have not done so (except for one video on Youtube) but it seems pretty easy and cheap. It might even solve food sensitivities! It should maybe even be further up on the list but it just feels so intuitively wrong to me.

• [revised] Try a bunch of other things. There are a lot of medications and pills you can take which have relatively low downsides and which can potentially be game-changers. This includes things like antidepressants, various supplements, nootropics, or other medication. Again, it's probably worth thinking of these as abnormally good lottery tickets. Expect most to fail but eventually something might really work. [see comments section for more on how to think about treating symptoms vs root causes]

Again, this is far from a comprehensive list. It would be great to hear from other people what possibilities they’ve come across and what’s worked for them. My guess is this is a more common problem than we think in the community. I really have no idea though. If this helps one person get more energy in the long-term I will be a happy (and less stressed?) person.

Thanks to Shay Gestal, Siebe Rozendal, Max Lauber, Lennart Heim, and my not-that-competent doctors

Last minute addition: Shay Gestal recommends these sources on sleep, nutrition (and biomarkers), stress, mindfulness, food sensitivities (hidden foods and elimination diets), pro/prebiotics, and gut restoration. I've only given them a quick glance but they seem solid!

Notes

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1. You should actually try these! If you’re like me you’ll think something like, “I read an article about that once so I’m probably doing that well enough”. It’s pretty likely you’re still not doing it very well. The effect is probably bigger than you’d think and you’re probably doing them worse than you think. While exercise is pretty easy to reason through there are a lot of non-obvious things to both sleep and nutrition. For example, did you know that having extra of some vital minerals can lead you to be deficient in other vital minerals even if you’re eating enough of them? (I’m not sure this is actually useful to know, just saying it’s more complicated than you’d think) ↩︎

2. This is because it seems likely that moving from the top 99th percentile of productivity to the top 99.1th percentile probably has extremely high value as you become more likely to pass the threshold for getting certain positions, achieving some research goal, being able to run some important organization, etc. ↩︎

3. The astute reader will notice that the earlier statistic says that 68% of people have lactose intolerance (i.e. a food intolerance). They might be able to infer that 15% is a whole lot less than 68%. I’m not sure what to tell this astute reader aside from that the literature on food sensitivities is terrible and I don’t have the patience to sift through it. ↩︎

4. Getting the right type of protein is one thing I haven’t seen many vegetarian food guides mention. My impression is that it might be easy to miss some amino acid types if you're not careful (e.g. tryptophan is almost exclusively found in meat/dairy and is the only way your body can make serotonin. Something which seems kinda important. Though you shouldn’t take it with other things which increase or affect serotonin like antidepressants!) ↩︎

5. Please don’t exceed the recommended salt intake of 2.3g though! ↩︎

6. Don’t do this if combining the things might be bad! This can be the case with some supplements and should be an assumption with many medications. For most of the suggestions below though you should be fine. ↩︎

7. I’m only not including sleep and exercise in here because I hear it talked about a lot. For example, if you always want to go back to sleep when you get up and/or you fall asleep very quickly at night or during the day you might need to sleep more (or better)! You should probably try to fix that before (or while) you try most of these other interventions. ↩︎

8. IMPORTANT NOTE: I only give this advice because I presume you all are fairly competent at doing your own research. However, if you haven’t done research before you will start out very bad at doing your own research (especially medical research)! This is ok but means that you should start with high deference to doctors and gradually decrease that deference as you learn more (this took a long time for me and I now do research professionally). Also, if you have a tendency toward health anxiety you might want to just listen to your doctor. Reading about symptoms can just lead to a bunch of psychosomatic symptoms (believe me). There’s a tricky balance to strike here. ↩︎