Tips for Beating Iron Deficiency

Iron deficiency is a common problem for distance runners. Often times runners don't think about their iron intake until it's too late, usually costing them a PR or even the rest of the season if the damage is bad enough. While fixing an iron deficiency isn't always simple, there are some simple ways to prevent iron deficiency and to support recovery when things go south.

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This article is not a substitute for professional advice. If you are dealing with iron deficiency, I highly recommend working with your physician and a registered dietitian.

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Why do runners need iron?

The main reason iron is so important is that it is an essential part of creating new red blood cells. The more mature red blood cells you have, the easier it is to carry oxygen to muscles aka you're going to have more capacity to run harder, longer. Iron also plays a role in bone health, which is one reason why athletes with anemia are also at a higher risk for stress fractures and low bone mineral density.

How do I know if I have an iron deficiency?

The best way to know is to get your iron levels checked (more on this below). Some signs that you might be struggling with low iron are feeling more tired than usual, having a hard time hitting splits or times you usually run without another explanation, or feeling out of breath. All of these would be beyond a normal amount of fatigue that comes with training. If you're new to running it can be harder to tell what's normal and what isn't, this is why getting your iron tested more frequently (once a year at least) can be helpful because it gives you a baseline to work with.

What is a good iron level for a runner?

This question is more complicated than you might think. While there are set values for iron deficiency and anemia, everyone has a different range where they feel good. The ranges that are used on an iron panel are also set for the general population, not athletes which is important to keep in mind. For example, ferritin is the iron-binding protein that is typically measured to detect anemia. A ferritin below 20 ug/dL would be considered anemic, but having a ferritin of 21 often isn't enough to feel strong as an athlete. Many athletes feel better above 35, 40, or even 50! The number you feel best at will depend on your baseline iron levels, which is why it's so important to get your iron tested frequently if this is a concern (and even if it isn't!).

How often should I get tested?

This depends a lot on your history as an athlete and your risk for iron deficiency. You may have a higher risk of iron deficiency if:

• You were anemic or had low iron in the past (TESTED low iron, not just you thought maybe your iron was low and started supplementing!)

• You are a vegetarian or vegan athlete

• You train at altitude or will be doing a training stint at altitude

• You are a female

• You're a heavy sweater

• You have a GI condition like Crohn's or Ulcerative Colitis

• You use antacids and anti-inflammatory drugs often (think ibuprofen or Tums)

• You don't eat enough or have a history of not eating enough

• You're an endurance athlete!

While some of these pose more risk than others, every endurance athlete should get their iron tested at least once a year. If you checked off multiple bullet points there, you might consider getting your iron checked twice a year or even four times a year if you are just coming back from being anemic.

Tips for iron tests

1. Ask your physician for the actual results/numbers. I had a physician who did a great job of taking into account that I needed a more iron as a runner, but sometimes your results are labeled as normal at the lab and you might not be notified even if your iron levels are on the cusp or lower than might be optimal for an athlete.

2. Don't take your iron test when you are sick, injured, or have just finished a hard workout. These can skew result of your test. Look to get it done after an easy day when you are healthy, preferably in the morning before you've trained. Similarly, getting iron tested RIGHT when you start exercising again can skew results. I recommend getting it done after summer/winter training when you've been consistently working out.

Supplementing

Supplementing is obviously a huge part of treating iron deficiency. While I won't go into too much detail here because I know how much runners love to self-diagnose and treat themselves (I'm also guilty of this), I do think there are some important things to note. First, recovering from anemia takes time. In fact, you often won't see results until about 6 WEEKS after you start taking a supplement and even then you might not feel like your normal self again.

While some athletes go for the "quick fix" of iron infusions, these often carry their own risk and do not fix the underlying problem, they're also rarely covered by insurance. If you have not gotten tested, it is essential to do that step first. Supplementing without being deficient can cause your iron to be too high, which will make you feel exactly like if it was too low! If you're curious about how much, how often, or what type of supplement to use, I recommend working with your physician. This looks a little different for everyone since some types are absorbed more readily and different forms of iron have different side effects.

Food First Approach

No matter who you are, eating foods high in iron will benefit you as an endurance athlete. You don't need to get tested to start eating higher iron foods because your body is able to regulate iron from food better than iron from supplements! If you are supplementing, food can be a great way to continue to keep yourself on track and build skills to keep your iron up if you decide to stop taking your supplement once your iron levels return to normal.

Iron can come from a lot of different foods. Sometimes it comes from plant-based, sometimes it comes from animal-based foods. Iron from animal-based foods is easier to absorb. Plant-based foods have lots of other helpful compounds that are great for separate parts of our health, but unfortunately not so great for absorbing iron. Read on to get an idea of how you can get iron from both and how you can maximize your absorption!

Avoiding Calcium, Adding Vitamin C

This goes for food and supplements. While you won't always be able to avoid eating calcium with iron and might not always get in vitamin C, these do make a big difference in your iron absorption. Try taking your iron supplement with orange juice or avoiding a big glass of milk at every meal. Good sources of vitamin C you can include citrus fruits, strawberries, broccoli, bell peppers, kiwi, and brussel sprouts!

The bottom line

While iron deficiency CAN be an easy fix, there are sometimes other issues going on that lead up to the symptoms many coaches and athletes automatically assume can be solved by adding an iron supplement. I encourage you to work with a health professional here. They can give you guidance on how to handle supplementing and can help you tease out why your performance is suffering. Sometimes it is as easy as adding a supplement, but if you keep experiencing issues you may want to dive a little deeper!

References

1. Hueglin, S. (2016). A Practical Approach for Developing an Iron Protocol for Athletes. SCAN's Pulse, 35(2), 10–14. Retrieved March 2023, from www.scandpg.org.

2. Cook JD. (2005). Diagnosis and management of iron-deficiency anaemia. Best Prac Res Cl Ha. 2005; 18:319-332.

3. Mahan, L. K., & Raymond, J. L. (2017). Krause's Food & the Nutrition Care Process. Elsevier.

4. Sim, M., Garvican-Lewis, L. A., Cox, G. R., Govus, A., McKay, A. K., Stellingwerff, T., & Peeling, P. (2019). Iron Considerations for the athlete: A narrative review. European Journal of Applied Physiology, 119(7), 1463–1478. https://doi.org/10.1007/s00421-019-04157-y

5. Braunstein, E. M. (2023, March 15). Iron deficiency anemia - hematology and oncology. Merck Manuals Professional Edition. Retrieved March 29, 2023, from https://www.merckmanuals.com/professional/hematology-and-oncology/anemias-caused-by-deficient-erythropoiesis/iron-deficiency-anemia

6. Mountjoy, M., Sundgot-Borgen, J., Burke, L., Ackerman, K. E., Blauwet, C., Constantini, N., Lebrun, C., Lundy, B., Melin, A., Meyer, N., Sherman, R., Tenforde, A. S., Torstveit, M. K., & Budgett, R. (2018). International Olympic Committee (IOC) consensus statement on Relative Energy Deficiency in sport (red-S): 2018 update. International Journal of Sport Nutrition and Exercise Metabolism, 28(4), 316–331. https://doi.org/10.1123/ijsnem.2018-0136

7. Braunstein, E. M. (2023, March 15). Megaloblastic macrocytic anemias - hematology and oncology. Merck Manuals Professional Edition. Retrieved April 6, 2023, from https://www.merckmanuals.com/professional/hematology-and-oncology/anemias-caused-by-deficient-erythropoiesis/megaloblastic-macrocytic-anemias

8. Kohgo, Yutaka & Ikuta, Katsuya & Ohtake, Takaaki & Torimoto, Yoshihiro & Kato, Junji. (2008). Body iron metabolism & pathophysiology of iron overload. International journal of hematology. 88. 7-15. 10.1007/s12185-008-0120-5. 

9. National Institutes of Health. (2022, April 5). Office of Dietary Supplements - Iron. Nih.gov. https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/

10. (2018, January 1). USDA National Nutrient Database-Iron. United States Department of Agriculture. Retrieved April 11, 2023, from https://www.nal.usda.gov/sites/default/files/page-files/iron.pdf

11. USADA (2020, July 8). Can Athletes Treat Iron Deficiencies? Here’s What You Need to Know. United States Anti-Doping Agency. Retrieved April 11, 2023, from https://www.usada.org/spirit-of-sport/education/iron-deficiency-treatment/

12. DellaValle, D. M. (2013). Iron Supplementation for Female Athletes: Effects on Iron Status and Performance Outcomes. Nutrition & Ergogenic Aids, 12(4), 234-239. https://doi.org/10.1249/JSR.0b013e31829a6f6b