… strong as iron…
“Gold has its uses, but war is won with iron” … George R.R. Martin – A Dance With Dragons
~ Dr Jarrad van Zuydam, a Johannesburg-based sports physician with a special interest in endurance sports medicine, and team doctor for the Dimension Data pro cycling team
~ Mariella Dierks, a registered dietician, elite triathlete and winner of the 2018 Durban Ironman 70.3.
What is iron?
Who is particularly vulnerable to iron deficiency?
Foods containing non-heme iron form an important part of a nutritious, well-balanced diet, but the iron contained in these foods won’t be absorbed as completely as the iron in meat. We only absorb between two and 10 percent of the non-heme iron that we consume.
What’s the difference between low iron stores and anaemia?
In the case of iron deficiency, you’ll only start becoming anaemic once that iron deficiency is severe. The body will be unable to produce more haemoglobin, and you become anaemic.
Importantly for athletes and runners, both anaemia and iron deficiency can cause a drop in exercise performance.
What is pseudoanaemia?
By definition pseudoanaemia is not a true anaemia. The definition of anaemia is a low level of haemoglobin in the blood. That haemoglobin is measured as a concentration in g/DL. Usually the absolute mass of haemoglobin in the blood is not measured (it can be, but it’s a more expensive test) – instead labs generally measure the concentration of haemoglobin in the blood.
What happens in athletes when we train is that we adapt to the training by producing more plasma, the liquid component of the blood. This helps to increase our cardiac output as well as the distribution of oxygen and nutrients to the muscles as we exercise – it’s a positive spin-off as one of the things that make us fitter, faster and stronger. But when we’re producing more plasma, the cellular component of the blood doesn’t increase as fast as the liquid component, which in effect creates a dilution.
Doctors need to be mindful of this dilutional effect when testing endurance athletes – aware that the test results may show anaemia, but actually simply appear that way.
(The other common occurrence of a dilution is during pregnancy – almost all pregnant women show a mild anaemia, which is actually a pseudoanaemia.)
What is the simplest, quickest and most inexpensive way to have iron levels checked?
So, the simplest place to start is with the rapid check, which will at least give us peace of mind in terms of a yes/no answer as to whether we’re iron deficient or not.
Iron toxicity and the risks of self-diagnosis
How to choose the best iron supplement?
Some of the newer iron supplements available are more complex molecules bonded with sugar, like polymaltose, and these are better tolerated. Unlike iron salts, these can be taken with food which helps minimise side effects.
Iron supplements can lead to constipation. Counter that by taking in enough liquids and fibre in your daily diet.
Can running at high altitude make us iron deficient?
Usually, elite athletes heading up to a high altitude camp for the purposes of increasing performance before an important competition like the Olympics, for example, would have their iron levels checked before leaving. Normal runners not going up to altitude, would have healthy ferritin levels of 30 or 40. Sports doctors prefer levels to be on the higher side of that number, knowing the body will be pulling from those reserves to produce the additional haemoglobin.
Symptoms of iron deficiency
Pale skin and fingernails
Best dietary sources of iron
Best vegan sources of iron
~ iron enhancers
~ iron inhibitors
Calcium is also an iron inhibitor, so avoid high-calcium foods during/before/after eating iron-rich foods.
Best iron supplement
Best way to prevent iron deficiency happening again?
Iron-related experiences from South African trail runners
India Baird (55, running for 32 years, vegetarian)
Anouk Baars (40, running for 3.5 years, eats meat)
When I got back to SA I had blood tests, colonoscopy and all the checks, due to the very low irons levels that were so obvious in the results. I started working together with my doctor and a sports nutritionist who did some additional tests, which showed I had the early stages of adrenal fatigue. People had been telling me I might be overtrained, but I knew I had trained very little in comparison with others, and that I had rested well between runs. The doctors couldn’t find any way I had been losing blood, so the gastroenterologist concluded it was caused by the running breaking down red blood cells through the pounding on my feet. As simple as that.
I started taking high doses of chelated iron (I am on Thorne research and Xymogen 100mg a day, some adrenal support supplements, a blood test every 3-4 months, and I eat wisely – I’ve cut out a lot of sugar and caffeine so that I can properly tell how my body is feeling every day without getting spikes.
Nowadays I take 60mg a day, and during my period or after a long race I increase the dosage for about 4 days to 90mg.
After about 5 months, things started to improve, and after 7-8 months I started to feel on fire! Suddenly I could do my big training weeks AND have energy for the rest of day.
Most people will drive long distance to fetch their phone if they’ve forgotten it at home. I’m like that with my iron tablets!
Riana van der Merwe (53, been running for about 11 years, eats meat)
I was not much of an ultra-distance trail runner then. I only ran to train for high altitude mountaineering, which had been our sport for that previous 10 years til the kids came along.
I started to run longer races at the age of 42. After children I have been using the mirena as a contraceptive, with success and no side effects, so I don’t lose blood due to periods at all.
About a year ago, I started to donate blood again as part of a project at our son’s school. I donated every 3-4 months, three times in a row. I started feeling as if I had no energy at all. I had other issues like an alcoholic father that affected me badly and at first thought that’s why I was so slow and weak. I still did races, but was extremely slow. About six weeks before TDS this year, I did everything I could to get out of the race. But it would’ve meant we’d lose the money we’d paid for the entries, so I had no choice. I decided I’ll just run half way or go along to enjoy Chamonix.
I always have annual blood tests to test for my iron as well as my thyroid. Ten years ago half my thyroid, and my parathyroid gland were removed due to a lump. The tests in January this year showed everything was normal in terms of thyroid and no cancer, but that my iron levels were 2, instead of 12 tot 15. My GP gave me 5 iron injections, under supervision, over 4 weeks. Even after the first injection, I could feel the difference while training.
The rest is history. Since then I finished the TDS and Skyrun. I have decided to not donate blood again, to listen to my body, and to have scientific tests done instead of self-diagnosing. I’m taking iron supplements for another few months.
Jess du Toit (33, been running for 3 years, mostly vegan)
The second time I found out about my devastatingly low ferritin and haemoglobin levels was when I went to see a psychiatrist for panic attacks and severe exhaustion. I was feeling worse than I’d ever felt in my life. I was completely exhausted all the time, no matter how much I slept. I could barely run for 3 minutes at a time, when previously I’d been able to run marathons. I had a foggy brain and was unable to think or concentrate at work. I’d become a shell of the person I’d been, and my relationships suffered. My self-confidence was at an all-time low and I started having the panic attacks.
One of the first things the psychiatrist did was test my haemoglobin and my iron levels. The results revealed the probable cause of practically all my symptoms! She recommended I see a haematologist for an iron infusion, as that would be the quickest way to have me return to feeling normal. She also put me onto Ferrimed – which I’m likely to be on for the rest of my life because I’m mostly vegan. It took a couple of weeks after the infusion to start feeling normal again. But the way I manage now is to be extremely careful about what I eat, and to not drink anything containing tannin, before or after a meal. I take my iron supplement religiously, and will do so for the rest of my life. I also go for blood tests every 3 months or so to monitor my iron levels.
Oriole Bolus (34, been running for 8 years, eats meat)
About 10 days before the race I started to feel weak in the mornings and really struggled to get up. I thought I had some kind of flu. I tried to go for a run, but had no energy – almost the opposite to how I’d felt a few weeks before. I still stood on the start line of Batrun, but only made it up and down Devils Peak before having to pull out. It was a weird feeling, I wasn’t sure whether I was sick or not. I thought it would pass but it didn’t. Two weeks later, I still didn’t feel normal on runs. So I went home to spend some time with my family in Plett and they sent me to a doctor who said there was no sign of flu or a virus, and suspected I may have depression. At the time I was busy with my Masters, and that was challenge in itself. After about a week I went back to Cape Town and tried to be as healthy as possible. I ate healthily and cut out coffee. My diet at the time was mostly vegetarian – lentil dishes with brown rice, and occasionally some fish. I also didn’t have much dairy. There was still no improvement, so I went to a doctor in Tokai who practices both conventional and homeopathy. Blood tests showed my iron levels were really low, and she recommended that I take iron supplements. It took about a month on the Fe supplements before I felt energised while running again, and another 3 months before I felt I could race again.
Later that year, I went overseas to do a Masters exchange for 6 months in Finland, and I began to eat more meat and dairy, and not running as much. I returned to Cape Town the following year feeling normal again, and ready to tackle some bigger runs. Since then, I’ve been upping my distance every year. I make sure I eat protein consistently, but also keep a varied diet. My body seems to have adapted to more training and I’ve been doing a few ultras, yet my iron levels seem to be good. Now it’s all about managing my lifestyle to keep the energy up and try my best to be consistent and avoid injuries.
Liesl Koch (38, been running for 4 years, eats meat)
I’m a REALLY slow runner but I’d been training for UTCT with Fred Richardson and was training really hard, sometimes even twice a day. I thought I was just tired from all the training, but my running wasn’t improving at all. I was starting to think that there was something holding me back. A friend of mine had told me to get my iron levels so I decided to get my bloods done. What harm could it do.
I’ve been taking Chela-Fer, and after just two weeks of taking the supplements I could certainly feel an improvement with my running. I’ll find out this week if my levels have improved sufficiently but I suspect they not quite there yet, as I’m really struggling with my breathing when climbing on trail. But hopefully it will improve.
Robin Sherry (68, been running for 20 years, mostly plant-based diet with fish and eggs)
Fortunately we have an excellent doctor who researches widely. So, after all the relevant tests to rule out underlying disease, I’m now on a diagnostic 3-month course of chelated iron supplements. This will probably confirm the problem is low absorption plus borderline low iron intake. Thanks to my doctor’s diligence, I got home to find links to relevant literature to help me inform myself. Vital. Now I know, for instance, not to drink coffee or tea within 2 hours of taking the iron. There is actually a lot to take into account for non-meat-eaters.
It has now been about 6 weeks on the iron and I’m at last feeling a lot better. I’m sure it has been a combination of lower absorption rates as I get older (68), and a lower iron intake, exacerbated by the interference of certain food/drinks when combined with the healthy foods. So in my case the running didn’t cause the problem, but rather led me to understand it. So we keep on running!
Jessica Magner (31, been running for 10 years, now eats meat)
So this year, I did things very differently. The two main things I changed were my diet (I decided meat is not so bad after all!) and I started strength training. I also took more supplements, and had regular vit B injections so that my iron levels did not drop again. It all seemed to work out this time as I had a fantastic race at UTCT! The 65km was the most epic race I’ve done, and I definitely think that supplements, right nutrition and good iron levels helped a lot!
Lynne Shepley (62, been running for 27 years, eats meat)