14 October 2015 ~ 2 Comments

Constantly Getting Dropped? Maybe you need more iron.

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Since 2007, when I started cycling, I have been training pretty diligently. Frequently, when riding with others my same age (or older than I), I get dropped. Earlier this summer, while getting some blood tests for a bladder infection/prostate problem, it showed my iron (Ferritin) was low. It was at 32, whereas normal is 22-275. For about eight weeks, I was taking one tablet a day (Nature Made 65 mg), along with 500 mg of vitamin C at night, before going to bed. That was ineffective, perhaps because I also snacked shortly beforehand (iron supplements are best taken on an empty stomach). So I starting take a liquid supplement called Floradix. I took 20 mg, three times daily. After eight weeks of that, it brought my levels up to 103. One medical professional suggested that for males, it should ideally be even higher, at 130.

After supplementation, my average speeds on the bike have also increased slightly. Also, I don’t feel compelled to always take afternoon naps (easy to do when you are self-employed with a house and office next to each other). If you are feeling like your endurance is suffering, it might be this problem. The $64,000 question is why does this happen? I have a read a few reports online, but nothing is conclusive as to why endurance athletes suffer with poor iron. Some speculate that runners have low iron, due to the pounding their body takes, but for cyclists?


The Mayo Clinic says [my additions]:

To diagnose iron deficiency anemia, your doctor may run tests to look for:

  • Red blood cell size and color. With iron deficiency anemia, red blood cells are smaller and paler in color than normal.
  • Hematocrit. This is the percentage of your blood volume made up by red blood cells. Normal levels are generally between 34.9 and 44.5 percent for adult women and 38.8 to 50 percent for adult men. These values may change depending on your age.
  • Hemoglobin. [A protein found in blood that aids in the transportation of oxygen to various tissues.] Lower than normal hemoglobin levels indicate anemia. The normal hemoglobin range is generally defined as 13.5 to 17.5 grams (g) of hemoglobin per deciliter (dL) of blood for men and 12.0 to 15.5 g/dL for women. The normal ranges for children vary depending on the child’s age and sex.
  • Ferritin. This protein helps store iron in your body, and a low level of ferritin usually indicates a low level of stored iron.

If your bloodwork indicates iron deficiency anemia, your doctor may order additional tests to identify an underlying cause, such as:

  • Endoscopy. Doctors often check for bleeding from a hiatal hernia [a problem of mine, which may or may not be bleeding], an ulcer or the stomach with the aid of endoscopy. In this procedure, a thin, lighted tube equipped with a video camera is passed down your throat to your stomach. This allows your doctor to view the tube that runs from your mouth to your stomach (esophagus) and your stomach to look for sources of bleeding.
    (For much of 2017 I was on a cardiaolgist-prescribed daily Asprin (325 mg). Sometimes I took it on an empty stomach [opps!] which contributed to a bleeding ulcer which apparently was the underlying cause of my anemia. Consequently I went from 325 mg a day to 81 mg and took it with food. Time will tell how this pans out.)
  • Colonoscopy. To rule out lower intestinal sources of bleeding, your doctor may recommend a procedure called a colonoscopy. A thin, flexible tube equipped with a video camera is inserted into the rectum and guided to your colon. You’re usually sedated during this test. A colonoscopy allows your doctor to view inside some or all of your colon and rectum to look for internal bleeding.
  • Ultrasound. Women may also have a pelvic ultrasound to look for the cause of excess menstrual bleeding, such as uterine fibroids.

These articles on the Training Peaks site are most helpful: Iron and the Endurance Athlete (best) or Iron Deficiency, Anemia and Endurance Athletes. The first link states (published in 2009, italics added):

If iron is the reason for the low hemoglobin (which is most often) then you have iron deficiency anemia [IDA].  However, if you have a low ferritin, but your hemoglobin is still normal, you only have iron deficiency [ID]. The difference is important as anemia is certainly more severe, but research clearly shows that having iron deficiency without anemia can lead to fatigue, lower productivity, and ultimately could lead to reduced endurance. In athletes, Iron Deficiency Anemia can lead to dramatic and measurable decrease in athletic performance, work capacity, reduced VO2max—and this effect is reversed when iron supplements are taken. The article goes on to say… If you are going to get your iron checked, remember to ask your doctor to check the ferritin along with your hemoglobin. There are a couple of problems with ferritin—first, it goes up, falsely, when you are under stress (i.e. sick, asthma, surgery, injury, infection, etc…), so make sure you are relatively healthy when you get it checked. Second, there is no “agreed” upon definition for a “low-ferritin” in endurance athletes…essentially, a good bet is if ferritin is less than 30-35  ng/mL then Iron Deficiency treatment needs to be discussed and if it’s between 35-60 ng/mL  increasing iron in your diet is a prudent step.

Also see this article on Active.com. WebMD does mention (in passing) that a cause of iron deficiency is those doing endurance training. This article, as found on LiveStrong site, talks about both B-12 and iron.

From this seemingly credible source (Sports Med Today):

An athlete with low ferritin and iron levels, and normal hemoglobin and hematocrit, is considered to have ID [iron deficiency), but not IDA [iron deficiency anemia]. If the athlete also has low hemoglobin and hematocrit levels, then he or she has IDA. For athletes with IDA, the evidence is clear that a daily oral iron supplement is beneficial in improving athletic performance. However, there is controversy about whether iron supplementation in athletes with ID alone is helpful.  The decision to start iron supplementation in ID should be shared between the athlete, physician, and potentially, a dietician. Iron supplementation without knowing iron levels is not recommended.

The Iron Disorders Institute says:

Other nutrients, however, such as vitamins C and B12, folate or zinc can facilitate sufficient non-heme iron absorption. Consuming certain foods and medications can interfere with the absorption of iron. These include dairy products, coffee, tea, chocolate, eggs, and fiber…Men are rarely iron deficient; but when they are, it is generally due to blood loss from the digestive tract (sometimes indicating disease), diseases that affect iron absorption, and in some cases, alcohol abuse. Except for those who are strict vegetarians, men rarely have dietary iron deficiency.

This 2013 article, as found on The First Endurance site, says quite simply “More hemoglobin = More oxygen delivery.” It says hemoglobin is “…the protein used by red blood cells to deliver oxygen and remove carbon dioxide from and athlete’s exercising muscles.” This article suggests tests which include a complete blood count (CBC) with differential, and an iron panel which includes: serum iron, total iron binding capacity (TIBC), iron saturation, and Ferritin.  They suggest “Living and training at altitude should stimulate red blood cell production to the high end of the normal range…in the above example the low % saturation and the normal TIBC tell us that this athlete’s body has the capacity to deal more iron.” With me, since I train at altitude (6000 feet), if my hematocrit and Ferritin levels are on the low end of the so-called “normal” range, that means they are actually well below the recommended value. (This is consistent with advice from the HealthLine.com which says “If you live at a high altitude, your hematocrit levels tend to be higher due to reduced amounts of oxygen in the air.”).

Causes of Low Iron

  • Inadequate diet
  • Strenuous endurance training, which can increase iron loss through sweat, gastrointestinal bleeding, and decrease iron absorption 1
  • Frequent use of aspirin or non-steroidal anti-inflammatory medications, causing increased GI blood loss 1
  • Running! Foot strikes (in runners/triathletes) can develop broken red blood cells called hemolysis1
  • Training at higher altitudes 1
  • Slow, chronic blood loss within the body — such as from a peptic ulcer, a hiatal hernia, a colon polyp or colorectal cancer — can cause iron deficiency anemia. Gastrointestinal bleeding can result from regular use of some over-the-counter pain relievers, especially aspirin. 2
  • An inability to absorb iron. Iron from food is absorbed into your bloodstream in your small intestine. An intestinal disorder, such as celiac disease, which affects your intestine’s ability to absorb nutrients from digested food, can lead to iron deficiency anemia. If part of your small intestine has been bypassed or removed surgically, that may affect your ability to absorb iron and other nutrients.  2
  • Vegetarians. People who don’t eat meat may have a greater risk of iron deficiency anemia if they don’t eat other iron-rich foods.
  • Healthline.com states that low hematocrit levels may be because of  “deficiencies in nutrients such as ironfolate, or vitamin B-12.”

1 = Ironman.com

2 = Mayo Clinic

A more recent CTS article, released in late 2017 says:

“ID [Iron Deficiency Anemia] is alarmingly prevalent in endurance athletes, with nearly 60% of all female athletes and 4 to 50% (Hinton, 2014) of all male athletes experiencing some form of iron deficiency in any given year.”

The classic 2002 book Serious Cycling, by Edmund R. Burke (p. 135): “Iron stores can be reduced in several ways. Periods of heavy sweating, for example, can decrease iron stores. Cyclists who sweat two to three liters per day may double their loss or iron…Cyclists who are vegetarians should be conscious of their iron consumption and make an extra effort to eat plenty of whole grains, nuts dried fruits, and other iron-rich foods…Female cyclists also need to be concerned with iron loss. Women lose an additional 15 to 45 mg each time they menstruate and stool.” He also suggests to eat foods rich in vitamin C and avoid drinking coffee at meals as it reduces iron absorption by up to 40%.

How Much Supplemental Dosage?

Unlike some supplements, like Vitamin C or D, too much can be harmful or even fatal. Consequently, a series of blood tests or “labs” are recommended first, i.e. complete blood count (CBC), which normally includes hemoglobin and hematocrit and then a separate draw for Ferritin. Iron supplements, if taken with some foods, like calcium or dairy, are not as effective. Most sources say it is best taken on an empty stomach, spread throughout the day. However I found that taking iron supplements with acidic additives like Vitamin C or an orange accelerated my ulcer, which in turn caused internal bleeding and made my condition worse!

In 2015, when I was first diagnosed with low iron, I started using liquid “Floradix Liquid Iron & Vitamin Formula,” a product developed in Germany. I took it in doses of 60 ml Floradix daily (20 ml liquid 3x day, or 60 mg of iron). I found it to be cheaper at Vitacost.com or ukhealthsupplies.com, instead of Amazon. The Floradix help-line person said that it can take two months to bring your iron up when taking the max. amount, which is 60 ml a day. She said that a 300 mg of regular iron pills (Ferrous Sulfate) only contains about 65 ml of Elemental Iron, whereas their product is full strength. Floradix is available in tablet form and takes longer to absorb but are just as good. The tablets are much cheaper. Too much iron can make one constipated.

In 2017 I visited with a DO “Sports & Orthopedic Medicine” physician and he suggested that for an endurance athlete like me, Ferritin should be the key indicator. It should be in the range of 250 to 350. Please note that in 2015 & 2016 the normal range was 22–275, but in 2017 it was adjusted upward to 37–400.

RaceReady Coaching suggests the following (2015): “The normal limits for the general population ARE NOT the same as the normal limits for athletes. Athletes should have a ferritin above 30 and the lower level of Hgb [hemoglobin] is 15.7 for males and 14.0 for females.
Here is where things can get tricky. You can have a completely normal hemoglobin and hematocrit, but, if your ferritin (i.e. the amount of iron stores in the body) is low, you may have symptoms of malaise and a decline in performance.A high TIBC is also indicative of low iron, because there is “room” for more iron to bind. Each of these parameters tells its own story which is why it is important to look at all factors rather than just a few.

This site (NYU) suggests: “a single ferrous sulfate 325mg tablet contains 60mg of elemental iron, so thrice daily dosing provides 180mg of elemental iron per day, well within the recommended daily range of 150-200mg for iron-deficient patients.”

This Triathlon site suggest the following:

How to Supplement Iron. An iron supplement should be paired with a significant source of organic vitamin C (non-synthetic). Organic vitamin C greatly enhances iron absorption. The key is that it must be “organic”. Synthetic vitamin C, such as that found in supplements does not have nearly the iron absorption enhancement effect as organic. Iron should not be taken with dairy products, or within 1 1/2 to 2 hours of drinking coffee or soda (this includes diet soda).
The ideal method for supplementing iron is to take it with a fruit smoothie. Vitamin C and protein containing lactoferrin increase absorption of the iron. Interestingly, dairy products, specifically cow’s milk have been shown to decrease iron absorption, while whey protein supplements containing lactoferrin increase absorption. The following recipe tastes delicious:
1 banana
1 scoop vanilla whey protein
1 cup frozen mixed berries
1 cup frozen strawberries
Coconut milk
(optional: 1 tbsp peanut butter or 1/3 cup rolled oats)
While supplementing iron, you should also supplement zinc, as iron supplementation decreases zinc absorption rates.

WikiPedia says: “Since iron stores in the body are generally depleted, and there is a limit to what the body can process (about 2–6 mg/kg of body mass per day; i.e. for a 100 kg/220 lb man this is equal to a maximum dose of 200–600 mg/per day) without iron poisoning, this is a chronic therapy which may take 3–6 months.

Livestrong suggests

The Centers for Disease Control and Prevention recommends that adults with iron deficiency anemia who are not pregnant take one 300 milligram tablet of ferrous sulfate, containing 50 to 60 milligrams of elemental iron, twice per day for three months. Elemental iron is the iron in the supplement that is readily available for absorption.

This site (not as credible as others) suggests, for runners in particular, that a minimum dosage of 120-200 mg of iron daily, after getting a Ferritin test. (They also endorse the cheap, but good NatureMade Iron supplements which are available through Costco).

Livestrong.com says maybe you need B-12 instead or in addition to iron… “Given the body requires vitamin B-12 to produce red blood cells, a deficiency in vitamin B-12 can directly lead to a deficiency in iron. In this way, the onset of anemia could be the result of a B-12 deficiency rather than an iron deficiency, although the relationship is indirect. This could result to confusion between the two, although they are completely different.”

This tri site discusses hemoglobin levels and suggests B-12 and other supplements: “As an endurance athlete, your dietary requirements of certain micronutrients are increased. Regarding oxygen delivery to the muscles, iron, folate, vitamins B9 and B12, vitamin C, copper, and vitamin A are critical to optimizing hemoglobin levels.”

First Endurance suggests a rather radical method to bring up one’s hematocrit levels and states (italics added): “The point here is that it takes years to improve total body iron stores with oral supplements, and may not even be possible at all.  The body has a difficult time absorbing enough iron to keep up with the depletion caused by high volumes of intense exercise. Intravenous (IV) therapy [of iron] is required to make any real, meaningful change.”  When finished with this 5-weeks series of infusions, you will be good to go for many years to come.
This is consistent with Wikipedia which says: “Additionally, pseudoanemia can be observed in athletes with adequate haemoglobin due to an increase in blood plasma in athletes that dilutes their haemoglobin concentration, making it appear as if they are anemic when they actually have an adequate amount of total haemoglobin.”

Read this post about when to take iron and about what foods inhibit the absorption of iron. “In most cases, the best time to take iron supplements is about one hour before or two hours after meals. Iron supplements are best taken with water on an empty stomach [along with Vit. C and/or a citrus drink].”

This credible source, i.e. CTS, written by ultrarunner coach Corrine Malcolm, says the following (Nov. 2017):

  • When hepcidin levels increase [inflammation caused by exercise], iron absorption decreases. Hepcidin levels peak 3-6 hours after exercise, which means taking an iron supplement on an empty stomach, or consuming an iron-rich meal immediately after a workout, is not likely the best plan. If you are a morning exerciser, focus on iron after lunch or before dinner. If you exercise in the afternoon, focus on taking your iron when you wake up.
  • Take your iron supplement every other day. Research suggests you’ll see a rise in your hepcidin levels for up to 24 hours after ingesting an iron supplement. The thought is that spacing your supplement intake to every other day increases your potential for iron absorption.

2 Responses to “Constantly Getting Dropped? Maybe you need more iron.”

  1. Jason T 24 July 2016 at 7:09 am Permalink

    What was your hematocrit and hemoglobin levels like during this time? Where they also relatively low?

  2. Rando Richard 4 October 2017 at 5:09 pm Permalink

    Opps, I missed this message. I did not have these two tested for some reason in 2015, but in 2016 and 2017 they remain low.

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