Iron Level Upkeep and Ferritin for Distance Runners

Ferritin The Unknown Factor

• What is Ferritin?
• Ferritin is a way to measure total body iron storage.
• Low Ferritin is an precursor to low iron and will indicate a chain of events are in place that will end in low serum iron levels. When Ferritin levels bottom out, total body iron stores are soon to follow.
• If Serum Iron levels are low it is way too late.
• Anemia will be the end result when iron levels bottom out.

Symptoms of Low Iron/Ferritin

• Heavy Legs/Butt
• Perceived exertion is greater than it should be for a given workout or race by both athlete and coach.
• Fatigue in races and workouts set in early.
• Sluggish during the day.
• Hard walk up stairs.
• Overly emotional or moody.

​

​

Symptoms of Low Iron/Ferritin Cont.

• Recovery seems to take much longer than normal.
• Shortness of breath while running.
• Low back pain may exist.
• Tired during school day and want to sleep all the time.
• Pasty color after races.
• Dizziness after races more than normal.

​

Causes For Low Iron/Ferritin

• Over-training. Excessive pounding of feet.
• Blood loss due to menstruation.
• Not enough iron rich foods being consumed.
• Women more likely to be vegetarians.
• Poor Nutrition.
• GI Blood loss.
• NSAIDS & H-Pylori
• Calcium conflict with iron rich foods.

​

Ferritin Goal Values

• Runners need to have a Ferritin level of at least 30 and preferably at 50 or more to be safe. A Ferritin in the mid 40s to 50 provides a nice surplus.
• If getting blood tested both parents & coaches should insist on getting Ferritin checked.
• Doctors are sometimes hesitant and don’t understand from the endurance runners perspective.

Doctors-How To Approach�as per Dr. Colter

• Doctors that are competitive runners or have an extensive background in running science are preferred.
• Normed Ferritin values for the population on the bottom end are not good for runners. In other words, it may say their values are within the lower limits of normal but that is not for an endurance athlete. We have had athletes as low as 12 Ferritin be told they are perfectly fine and this is far from being fine for our sport.

What to do if Ferritin is low?

• Intravenous Iron Infusion.
• Expensive and only masks the problem and may not actually help.
• Improve Nutrition
• Cook in cast iron skillet
• Eat red meats if possible (Heme based foods)
• Eat veggies/grains high in iron (Non-Heme based foods)

What to do if Ferritin is low continued?

• Supplementation
• Iron Sulfate Pills (Wal-Mart)-Non-Heme based
• 3-5% absorbed
• Has some side effects like nausea, bloating and constipation.
• Can raise iron stores 2-3 points a week.
• Proferrin ES (Colorado BioLabs)-Heme based
• Up to 25-30% absorbed
• Not as many side effects.
• Can raise iron stores 5-6 points a week.
• HemeVite (Apex Energenics)-Heme based
• Nature Made Iron 65 mg
• Thorne Research - Iron Bisglycinate - 25 mg Iron Supplement for Enhanced Absorption Without Gastrointestinal Side Effects

​

Other Helpful Pointers

• Avoid Calcium (dairy) consumption within two hours of eating iron rich foods or supplementation. Multi-vitamins contain calcium sometimes.
• Combine iron rich foods with foods that contain Vitamin C. Vitamin C will be a catalyst in iron absorbing.
• Avoid NSAIDS. (Ibuprofen and Naproxen)
• One pill can take SOME individuals back four full weeks according to Dr. Colter.
• Avoid Caffeine products.
• Get Ferritin tested at end of track and cross country.

High Iron Foods (Heme Based)

• Red Meat
• Egg Yolks
• Mollusks (Clams, Oysters and Mussels).
• Liver.
• Turkey and Chicken Giblets

**Iron stores from Heme Based sources store up to 30% of iron.

​

​

High Iron Foods (Non-Heme Based)

• Dark Green Leafy Veggies (Spinach, Collard Greens).
• Dried Fruit (Prunes and Raisins).
• Iron enriched cereals like Total.
• Beans, lentils, chickpeas, soybeans.
• Artichokes

**Iron stores from Non-Heme based sources at 5-10%.

​

Other Factors

• Celiac Disease
• Gluten Sensitivity
• Helicobacter Pylori (H-Pylori)-upper GI tract
• Hemochromatosis (excessive iron)
• Ferritin above 200
• Modification of workload and workouts needs to be considered until Ferritin levels are back to normal.
• Thyroid Issues

​

​

​

Educate Yourself

Educating yourself on these issues is very important. Here are a few things every family should be thinking about in regards to iron/ferritin levels:

• Educate yourself on what iron does for you as a runner, and how it can hurt when you are lacking.
• Get your ferritin levels tested 2-3 times a year by your medical provider, and know your numbers. The off-season is the best time to get your levels checked.
• Set a goal for yourself to get your ferritin levels to at least 30. 40-50 is better, and gives you a nice surplus of iron.
• If your ferritin is under 20, you are most likely not going to be able to perform at your best as a distance runner.
• Eat lots of iron rich foods daily such as red meat and spinach.
• Take an iron supplement, and talk to your medical provider about how much you either should, or should not be taking.

​

​

Talk To Experts

In the coaching staff's experience some doctors are hesitant to test for ferritin levels because they do not fully understand the critical role ferritin plays in endurance athletics. Below is a letter from Dr. Kim Colter (Washington, MO) w/ references, about ferritin levels for endurance athletes that you can take with you to your medical provider when you ask to get tested. Please take this letter with you so that your doctor fully understands why it is you are asking to have your ferritin levels checked.

Dear Doctor

�The runner you are seeing is requesting that serum ferritin be tested to assess total body iron stores. In my experience, there are many distance runners who are iron deficient without being anemic or microcytic and these runners are not able to perform optimally when their serum ferritins are below 30. Iron deficiency for runners is not simply an issue of having adequate hemoglobin. At least one muscle enzyme involved in lactate metabolism, alpha glycerol phosphatase, is an iron containing enzyme and inadequate levels of this enzyme make runners incapable of racing and doing hard training. The listed lower limits of "normal" for ferritin values vary from lab to lab, and are sometimes listed as low as single digits. Runners with serum ferritins below 30 do not perform well. I encourage distance runners who are running year round to test their ferritin twice a year. Testing at the end of fall cross country season and after outdoor track season is over in late spring will allow identification of runners who are deficient in total body iron stores in time to allow replenishment of those iron stores by supplementation prior to the next season of hard running. Many runners require iron supplementation while running in order to prevent the development of iron deficiency. ��

While iron deficiency is more common in female distance runners, male distance runners experience it as well. Hard running and racing lead to transient ischemia of distal colon and rectal mucosa with proven increased losses of iron in stool compared to sedentary controls. �

In my experience, testing for the development of anemia is testing for the last thing that occurs in iron deficiency. Testing ferritin is much more helpful in detection of iron deficit in runners than testing hemoglobin alone. Certainly, testing hemoglobin, HCT, and MCV may be useful in discovery of anemia that is due to factors other than iron deficiency. �

If I can clarify my opinion regarding iron in runners please feel free to contact me at coltmenk@hotmail.com. �

Kim Colter MD�Washington, MO��

References

Am J Dis Child. 1988;142(2):165-169. doi:10.1001/archpedi.1988.02150020067030�study showing that adolescent runners with normal hemoglobin and low ferritin demonstrate improved running performance with correction of iron deficiency as measured by serum ferritin concentration. ��Finch CA, Miller LR, Inamdar AR. Iron deficiency in the rat. Physiological and biochemical studies of muscle dysfunction. J Clin Invest. 1976;58:447–552.�rat study in which rats with normal hemoglobin and reduced total body iron stores have poorer exercise tolerance and higher rate of lactate production during treadmill exercise than iron replete group of rats with the same hemoglobin concentration.��Int J Sports Med. 1996 Oct;17(7):473-9.�Iron deficiency in distance runners. A reinvestigation using Fe-labelling and non-invasive liver iron quantification.�Study demonstrating the increased loss of iron in stool in runners who are racing and performing quality training.

Articles About Iron for Distance Runners

I have included several articles below about this very important issue to help you educate yourself on the matter. Please feel free to talk to the coaches if you have additional question.

• Iron Level Upkeep for Distance Runners
• Are Your Ferritin Levels Up to Speed? Top Coaches Take Tests for Iron Seriously
• Ironing Out the Details: Know the facts about ferritin and iron before deciding to supplement
• Iron Deficiency In Runners

​