Could Low Iron Be Slowing You Down? Nutrition Deep Dive on Iron Deficiency in Endurance Athletes

Feeling more fatigued than usual? Struggling through workouts that used to feel easy? If your training isn't matching your effort, low iron could be the missing piece.

In this solo episode, sports dietitian Katie takes a deep dive into one of the most common—and often overlooked—nutrition concerns in endurance sports: iron deficiency. Drawing from both the latest evidence and her own experience as a collegiate runner who battled severe iron deficiency anemia, Katie explains why iron is so critical for performance and how even "normal" lab results may not be optimal for endurance athletes.

In this episode, you'll learn:

• Why endurance athletes are at higher risk for iron deficiency
• The early warning signs that often appear before anemia develops
• Which blood tests to request—and why a CBC alone isn't enough
• Optimal ferritin levels for runners, cyclists, and triathletes
• The best food sources of iron and how to improve absorption
• Common mistakes that can reduce iron absorption
• When iron supplementation is appropriate (and when it isn't)
• Practical strategies to prevent recurring iron deficiency while training

Whether you're training for your first marathon, preparing for an Ironman, or simply wondering why your energy has been lagging, this episode will help you understand how iron impacts endurance performance and what steps you can take to stay healthy and perform at your best.

If you've ever wondered whether your fatigue is "just training" or something more, this episode is for you.

For coaching inquiries:

Coach Katie → https://fuel2run.com

Coach Justin → https://tabularasaracing.com

Podcast Email → theenduranceathletejourney@gmail.com

Transcript

SPEAKER_01 0:09

Hello, everybody. This is Katie, and I am a co-host of the Endurance Athlete Journey podcast. And just coming at you, I'm recording another solo episode deep dive into the topic of iron deficiency in endurance sports. The reason that I'm doing another deep dive is just that I've been away for the past three weeks with some travels. If you have been following my Road to Grandma's episode, you will kind of get a gist for what I've been doing, but I haven't really had a chance or opportunity to record an episode with Justin. So we've been doing some solo episodes and trying to kind of fill in the gap while I've been gone. And this particular week we just didn't have a chance to record. And so I am going to come at you with another solo episode, another deep dive. So I do apologize for having sort of this solo episodes that we've been doing where it's just been one of us and not both of us. So hopefully we'll back to be back to our normal routine next week. But I thought I would do this episode on iron deficiency because it is super common in endurance athletes. And I've actually struggled with it myself quite a bit. And so I'm wanting to share my own journey or my own struggles and my own story with it, and then a little bit about what it is, what are the symptoms, what are things that athletes need to know? How do we test? What are we testing for? How do we supplement? Should we supplement? So kind of answering all of those questions. First of all, I kind of wanted to just mention that sometimes when an athlete is experiencing something like low energy or feeling fatigued or maybe feeling like they're not making progress with their training, it may not necessarily have anything to do with whether or not they're fueling enough, whether or not their training is actually adequate. It may have everything to do with low iron and it's a common thing that athletes experience. So I do think it's worth diving into and digging into and getting a little bit more familiar with so that if you're experiencing some of these things, it might be worth testing and kind of getting this figured out for yourself since it is common. I think that's why this topic is really important because I think a lot of athletes kind of hear about it. But even if you do go in for testing, what your doctor's looking for may be completely different than um are the levels that your doctor may be looking for on um a blood panel may be different than what's actually optimal for endurance athletes. So sometimes this can actually be missed, where a doctor may run an iron or ferritin and say, oh, you're normal, but in reality your levels are actually too low to support your endurance training. And that I've seen happen quite a bit. So we'll even talk about the like actual levels you want to be aiming for and the tests that you want to be doing. As I mentioned already, this is one of the most common nutrition concerns in endurance sports. And fatigue can have many causes. So sometimes it's really hard to figure out when you're starting to feel the fatigue where that's coming from. And so this is just one avenue to kind of look at when we're looking at um diagnosing or figuring out the underlying cause of the fatigue. I want to go into sharing a little bit more about my history with iron deficiency anemia. I'll give you a little bit of my story, and then we'll kind of dive into the gist of the episode: the what is iron actually doing, why are athletes at a higher risk, what were the symptoms, how are we testing, that kind of stuff. But my history with iron deficiency started back when I was actually, probably actually started back when I was in high school, and I didn't really get it figured out until I was in college. So as a high school athlete, I decided to go vegetarian for a good last few years of my high school career, I suppose. And so I reduced and took out almost all um, I took out all meat. So I didn't eat meat, but I was still eating dairy and eggs for the most part. So I was um pretty much vegetarian. I don't remember, I might have ate some fish, but so maybe more pesca vegetarian, but I really did eliminate all meat. And I also kind of went through some struggles of low energy availability in that at that time as well. So it's hard to say kind of what caused what or what happened first or why the, you know, when the fatigue started, if it was iron deficiency or low energy availability. But I struggled a lot my senior year of high school with performance. And so, you know, that's kind of probably the beginnings of the iron deficiency or the low energy availability. But I struggled a lot, couldn't figure out what was exactly going on, frustrated that I wasn't doing well, and then move forward a little bit into college. So when I got to I ran, um walked onto the team at CU Boulder. So I did somehow manage to, even though I struggled a bit in my senior year of high school, manage to walk on to the team at CU Boulder and was running for them, but was really struggling, continuing to struggle my freshman year of college with just fatigue. I remember running, going for runs and just kind of looking at a shady patch of grass and thinking, wow, I really wish I could take a nap. I really wish I could sleep right now. And that's just not a normal thing. I suppose it could be if you're just tired generally, but this would happen a lot where I just kind of be like, oh, you know, I'm just tired. I would struggle going up the stairs and just kind of felt like something was going on. And also another underlying factor here was that I went from sea level to altitude, which can also be a risk factor for iron deficiency. So I had all of these little things happen. Plus, I decided my freshman year of college to go um vegan. And so there's a lot of little factors that were leading to this. But I remember being really tired, really fatigued, my performance was dropping, I wasn't doing well. And I remember the coach on the team kind of being like, all right, like this isn't things aren't going well. We're gonna have you test, we're gonna do some blood work, and having that blood work come back. And literally, I remember the coach saying, Your iron levels are some of the lowest I've ever seen. I'm surprised you can still run. I'm surprised you're still out there running. Um, but you need to get on an iron supplement ASAP because the levels were so low, I think my veritin was 11. You know, maybe it was lower. I can't remember the exact number, but it was pretty low. And the coach was kind of like, yeah, you if you can still be running with this level, I want to see what you can do when your levels are higher. And essentially, the only reason I got to stay with the team because I was failing for performance was because he had some faith in what I might be able to accomplish if my iron levels were higher. And so I did start taking an iron supplement. I did actually add meat, red meat back in because, you know, I knew enough to know that red meat had a was higher in iron. That was a tough one for me because I had been vegetarian and vegan, but I kind of knew what I had to do for performance was going to be different than what I was wanting to do for ethical reasons or even health. Um, although this in this case, what was most healthy for me was to be back on eating back to eating red meat and and animal products. So I did make a few adjustments and was able to get my iron levels up and essentially was able to perform better with that, even though I still probably struggled in other areas of nutrition. I don't think I was perfect after that. Still probably had some issues with fueling adequately, but I was able to get my iron levels up with the supplements and adding red meat back to my diet and um was able to perform better. Ever since then, though, I have had an issue with low, lower than optimal iron levels. It's always been a struggle. Even as I've added red meat back in, and even as I've supplemented, I've had a really hard time getting those levels up to where they're optimal. So it's common, very common in endurance athletes to see that even if they're eating red meat and they're not vegan and they're not vegetarian to have issues. And there's especially an issue or a concern when someone is deciding to go vegan or vegetarian because they're not taking in the most absorbable form of iron. So it becomes an even more of a an issue sometimes or something that needs to be sort of uh tested for and looked at to ensure that iron levels are normal. But um, so you know, I I started taking in and felt better, but it's it's definitely something, if this is something that kind of resonates with you, or you're feeling like, wow, yeah, I'm really fatigued. I'm just tired all day, or you're not getting out of training what you think you should be, this is always something to look at if you haven't already looked into it. So let's talk about why iron is so important for endurance athletes. So essentially what happens is the red blood cells have iron, and the iron actually attaches to oxygen and it kind of carries the oxygen to the working muscles. So when we don't have enough iron, it doesn't work, the red blood cells don't work properly. There's a reduced ability to carry that oxygen to our working muscles, and that can be really critical in um obviously producing energy and you know having um the energy we need to be able to perform. So it's just basically helping that oxygen is necessary to help produce the energy inside the cells. Iron is also critical in immune function, so when we have low iron, that can also mean lower immune function. Um, and it's just important for recovery and adaptation and training. So it just kind of helps us having adequate oxygen, having that iron. There's other things that iron is doing in the body that kind of helps us recover, that helps us support the immune system. So it's really critical in many areas. But I think the most important thing for endurance athletes is just making sure that we have enough iron so that we can have that part of our red blood cell to bring oxygen to the working muscles. And without that, we're gonna feel tired because we aren't gonna be able to get the oxygen that our body needs to produce energy. Um, so oxygen delivery determines athletic performance. That's key. Without it, you're gonna sort of fail to perform. Um, and even a mild deficiency can impact training even before a true anemia develops. This is why it's so important that when you get tested, you don't you have a doctor that's um aware of the implications of low iron in endurance athletes, and that what's maybe normal on a test isn't always what's optimal for endurance athletes. So something to keep in mind when you're looking at the test and talking with your doctor about it is making sure that they're looking at it from the lens of what is optimal for endurance athlete, not just like, oh, well, your levels are 15 and that's okay because they're just outside of the, they're just outside of that low or or anemia level. So you're fine. That's actually not fine. That's too low. So we'll talk about the levels, but just something to um keep in mind. So there's a lot of factors here that influence iron and what can influence why athletes and endurance athletes particularly struggle so much with low iron, is that first of all, the uh iron comes from our food. And so the first thing I kind of mentioned in my own story was that I was decided to go from meat-eating to vegetarian to vegan. And there's nothing really wrong with that. I'm not saying that you shouldn't, if that is the way you want to go with your diet, that you shouldn't do that. I just think you need to be aware that the foods that you're consuming when they're plant-based are not, it may have iron, yes, but the form that it's in is not going to be as bioavailable. The most bioavailable form of iron is heme iron, and that is going to be in our red meat and um dark meats. Non-heme iron is the type of iron that we find in plant sources, and that is not as available. Sure, you can have vitamin C, you can try to do some things that will enhance absorption, but you're at risk if you're going to do vegan or vegetarian for iron deficiency anemia. It doesn't mean it's guaranteed to happen, it's just more at risk. So it's important to do the testing and maybe find sources that are high in iron, or you may have to supplement with iron. Now, again, you don't want to just supplement willy-nilly, you need to do the testing before you start taking iron because high levels of iron is also not good for us. So low levels are bad, super high levels are bad, and some people do have a tendency for high levels. There's a condition called hemochromatosis, which is basically where red or where um iron kind of accumulates in the liver and it can be really bad, and that can't be a genetic. So we always want to test before we just start taking um especially high levels of iron. You know, you could, if you're deciding to go vegan or vegetarian, just take a multivitamin with, you know, 10 to 20 milligrams per day, if you're just wanting to kind of cover your bases, but we just want to be aware that that is a risk factor. So low meat diets are going to be a risk factor just because of the bioavailability of iron. Another thing that is for women specifically, we lose blood every month in our menstrual cycle. So if you're, you know, a woman in particular might be a little bit at higher risk because there is that blood loss that's occurring and you lose iron in that blood loss. So women do happen to be at a little bit of an increased risk. And so it's important for really active women to also get tested as well. Um, sweat loss. So there is a little bit of iron that's lost in our sweat, not a ton, but a little bit. Foot strike hemolysis is another one we want to consider as endurance athletes. Every time we hit our feet on the ground, there's a little bit of there's a red cell blood blood cell death. Not like it's like killing a bunch of them, but it does happen. It's just the force of the impact on our feet on the ground, and there can be red blood cells that die in the process. And that with that we lose a little bit of iron. It's not so much that, you know, going for run one run, it's just the repetitive red blood cell damage that's occurring over time, over several, you know, over several miles or strikes of the foot. And so it's not um extremely significant, but it does play a role. So we want to keep that in mind, and that's another thing that puts endurance athletes at particular risk, particularly runners, because of that foot strike hemolysis that's occurring. Um, sometimes if you, you know, someone's having some gastrointestinal bleeding that might occur during a long exercise or for other reasons. I mean, obviously, if this is happening and you're noticing blood in your stool, you probably want to get that looked at. Might be something more serious, but sometimes we just have the the gastrointestinal systems a little bit impacted by those long endurance rides. You might not even notice that there's blood in the stool. It may be so such a small amount. Um, but that's a potential factor. Um, if you donate blood, you know, I remember being in college and my uh coach was like, absolutely, you cannot donate blood. It was like forbidden. And I know it's great. Like, I want I don't want to discourage people from donating blood because it obviously saves lives. But if you're doing that, you may absolutely need to be looking at your iron levels. And maybe even if you're an endurance athlete donating blood, you may want to consider supplementing um iron just to make sure you're getting enough. And sometimes even with frequent injuries or surgeries can impact this. Um so, you know, just the ability for the body to recover or tissue to repair in in the instance of recurring injuries, you might be a little bit at risk because you're maybe losing, especially if you've lost some blood or you've had an actual surgery where there may have been some blood loss. We do want to be aware of that. Higher training volumes put you at risk. Adolescents are more at risk because of their growth and their need for more iron for growth. Um, anytime we have the need to build new red blood cells or more, so when we're training at altitude, because we are going up in altitude, we are actually increasing red blood cells. That is an increase in demand and needing more iron. Um, so those are just some people that are going to be at risk. And anyone that's like suffering from relative energy deficiency in sport or red S or for some reason restricting their energy is also at risk. So more at risk populations tend to be the female endurance athlete, vegetarian, vegan athletes, um, high volume training, altitude training, and adolescents and those who are under fueling or under consuming. So let's see, let's talk a little bit about the stages of iron deficiency. So the first stage is just kind of an iron decline. This is maybe not where you're going to notice the significant disruption of performance, but you might start it, there might be some subtle things that are happening. And this is where iron stores are declining. So ferritin is starting to decrease, hemoglobin is maybe still normal, athletes may still feel like they're pretty normal, but you can start to see there's this decline, especially in the ferritin levels, and we'll talk about what that means when we talk about labs. Um, stage two, there is a actual iron deficiency, you're not or deficient, but you're not deficiency. It's like you're starting to be depleted. I would call this more like iron depletion, but not necessarily like a full-on deficiency yet. And this is where you start to see the ferritin come down. You might actually see changes in the other blood markers uh for iron. Um, you may not necessarily see like a change in the seep complete blood count. So hemoglobin hematocrit, those might all look okay still. But some of the other markers are starting to be to indicate iron um levels are declining. And this is when usually performance starts to suffer. So this isn't, it doesn't start to suffer when we have a true iron deficiency anemia. It starts to suffer when we sort of go to the stage two where we're sort of seeing declining levels, but the actual blood levels that you're getting through a CBC might actually be normal. So if your doctor is just running a complete blood count and hasn't done the full iron panel or a ferritin, that's not going to be enough. You need to do a full panel to be able to really see because it's not going to be shown in this stage two, isn't it? You're not going to see that, but you're going to start to see the performance suffering. And then stage three is the true iron deficiency anemia. So this is really where we have, like in my case with that low-loferitin, I was likely in this iron deficiency anemia stage. Um, I don't remember having any other blood markers done, but locally my hemoglobin would have been a little bit on the low end. Um, but that's when the reduced oxygen compare carrying capacity starts to really kick in, and you start to experience significant fatigue and a decrease in performance. Um let's talk a little bit about the symptoms here and what you might be looking out for if you think this is happening to you. Some of these symptoms may be more so in stage three, true iron iron deficiency. So we'll try to kind of just differentiate what stage, you know, what we might see first versus what we might see in a later deficiency stage. But it's really gonna be usually fatigue is gonna be your number one indicator. So if you're experiencing some sort of unusual fatigue where you're just tired and can't really you wake up and you're like, I can't really figure out why I'm still tired. This is probably going to be that stage that some of you would notice even before a true iron deficiency. It's gonna get worse when you become deficient, but it's just that lingering kind of fatigue where you're not really feeling like you're getting much out of your workouts, you're feeling like you're working hard, you might be a little bit out of breath. Um, those are some of the symptoms there. Maybe workouts are starting to feel a little bit harder than you expected. They're not quite where you needed them to be in terms of what you're expecting. Um you're just feeling like you're breathing harder than you should, or you're not um recovering like you should, that kind of thing. Um, heart rate may increase a little bit here, so your heart rate may, you might notice a little bit of a heart rate increase. Um, like I mentioned before, shortness of breath, declining race performance, just maybe your times aren't getting better, or you're worsening, your performances are worsening. Another one would be maybe feeling cold often, and that's probably going to be one that you would experience more in like a deficient state, where you're just kind of like, oh, I'm kind of cold. You could see how this some of these symptoms could also be other symptoms of other things. For instance, like my having um a thyroid issue. So sometimes feeling cold might also be something like that, or heart rate m changes may may also be related to some something else like a thyroid. So you could see how sometimes these symptoms may be confused for something else, or it can be sometimes hard to differentiate what might be. going on. Maybe you get sick often or you struggle with concentration or your legs feel heavy or you're just not as motivated. I mean these could all be different things that could be causing that, but iron, low iron could be potentially a reason. So we always want to kind of consider low iron whenever we're looking at someone, whenever I have someone complaining of these types of symptoms, I always want to consider iron and as well as other things. But I may say like, okay, like I'm not sure what's going on. Let's run an iron, let's get a ferritin. That's a pretty cheap test. Let's just kind of rule that out or see if that might be contributing. And then we can go down for avenues of like what might be causing some of this. Because obviously reduced motivation could be a lot of different things. Maybe you've been just training a lot and you're starting to feel just the need to take a break or maybe something else is going on in your life and you're just not motivated to train. I mean there's so many different reasons for that particular symptom. And so sometimes it's kind of asking those questions and trying to get to the bottom of okay, well how are you feeling during your training? Are you unusually out of breath? Do you feel out of breath going upstairs when normally you wouldn't be or you know those types of questions. And and and kind of differentiate between is this overtraining, poor sleep, lack of fitness, maybe not training enough, stress, like those are all things that can cause some of those symptoms. So it's really trying to get to the bottom of what might be the underlying cause. And like I said, sometimes it just doesn't hurt to do a quick like iron panel or just a ferritin to sort of see you know kind of get at least some information about what might be going on. So symptoms can be kind of vague. Sometimes they can overlap with other things. So it's just a matter of kind of trying to figure out what might be the root cause of the symptoms and then moving on from there. But I do think blood tests can be revealing. So if it's un if an athlete is coming to me and they're like I'm experiencing these things I don't know maybe we've ruled out okay it doesn't sound like you're it sounds like you're sleeping okay it sounds like you're not overtraining your training seems adequate. Okay it sounds like you um are eating enough like overall your calorie intake isn't under fuel you're not under fueling necessarily once I've kind of ruled out all of those things then it might be like okay I really think it's a good idea to go get a blood test done. And blood tests are great. You know I think blood tests can give us a little bit of a look under the hood to see what's really going on and get a little bit more information because it's actually showing us what's going on in our body. And so common labs that we might look at would be a complete blood count or a CBC. That one like I mentioned will not show us level one or level two or those first two stages of iron deficiency. It's not going to show us because the body is going to tightly regulate what's going on in that um that basic blood panel. So if your hemoglobin or hermatocrit are are low or there's something happening there, then that um that's pr that's probably not a good thing because that means you are truly deficient. And so we don't want to rely on a CBC on its own because it's not going to it's only going to show us when somebody's extremely deficient. So you could have that done and be like your doctor would be like oh it looks like your levels are normal but maybe they're really not and so because we're not looking at the other markers of iron and so we really don't want to let rely on the CBC alone. What we want to look at are some of these other things. So ferritin is the storage form of iron and so that's really telling us when our ferritin is low, that's kind of telling us that our levels are lowering. We don't have any more room to budge because the levels in our body is kind of what we've got we don't have any storage iron. Storage iron is kind of there just in case it's to help us you know when we have a surge or need for iron to be able to have a little bit in reserve. So if your levels are so low that you have very little in reserve that usually indicates that maybe you also have low levels elsewhere and that it's going to be suboptimal. So ferritin's probably the very first one if if someone had to choose one thing to check, I would check ferritin. Now here's the kicker depending on the lab place you get it or what where you get your labs done, the reference range is going to be a little bit different. But typically it's something like 12 or 15 is the cutoff and anything below that is going to be considered low or too low. And anything above that is going to be considered normal. Well I'll tell you right now like a hemoglobin of 15 is not normal for an endurance athlete. In fact I don't think that's probably good in general but like that just because that's the cutoff doesn't mean that when you're just a little bit above that cutoff that somehow you're okay. Your levels are still low and too low for what's optimal for endurance athletes. So if you go and your doctor says oh your levels are 20 or 15 you know you oh you're fine you're probab you're not fine because your symptoms that you're experiencing of poor performance are absolutely justified because your iron levels are not optimal for endurance athletes. What I tell people because the upper limit is like 150 or 200 so or me I think it's like 200. So you can see how like 12 to 200 is a big range. You know, just being a little bit over that value of 12 or 15 or whatever that cutoff is is just that just happens to be the cutoff. That doesn't mean that's what's optimal. For endurance athletes I tell people a minimum of 30 and even at 30 it's still a little bit low than what's optimal. But I try to say like if it's below 30, that is not good for endurance athletes. That's where we need to work on it. 50 to 150 is probably more optimal for a ferritin for endurance athletes. Obviously as we kind of tick up higher you know there could be as someone's kind of hitting up towards 150 or something like that, then it's maybe like all right like this is okay but we want to kind of keep an eye on it because we don't want to have it go too high. But most endurance athletes that come in are definitely not that high. Most people are less than 100 and anything less than 30 is not good is not good. We want to try to improve from there. I'll tell you one thing I am always like if I don't supplement I'm always at 30 or less. Even when I'm taking in red meat I've always struggled with this. To get to 50 is a challenge for me. So I'm either genetically or there's some other thing that maybe just my needs are higher or I'm just not absorbing it as well but I always struggle to get it higher. And so it does sometimes become a little bit of work to get it there. But 30 is kind of the cutoff for me the minimum for endurance athletes and optimally more like 50 to 150 on the ferritin is where I like to see it. Now sometimes people will do a full iron panel and that gives us a little bit more information about what might be going on. So like serum iron if that's low then that's kind of what's happening in our blood and what's kind of hanging out in our blood. So if that's low that might be an indication of even more concern or total iron iron binding capacity is another one we might look at and that's like how much iron is bound up and the higher the total iron binding capacity the more iron deficiency deficient we are because the the iron the capacity to s to bind iron is not full. Like so if we have a low iron binding capacity that means like all the iron are bound up and that your levels are probably okay and if it's so it's kind of the opposite of what we would think. Another thing we might want to look at if ferritin is high but all the other markers are low or there's something kind of wonky going on with ferritin it's not really trending this is why doing a full iron panel can be helpful sometimes to see oh ferritin looks normal but you're still experiencing symptoms and it looks like iron is actually the other the other markers are actually telling us the iron is low. Sometimes I'll have someone do like a C reactive protein because inflammation can kind of elevate ferritin and so sometimes if ferritin is a little wonky or something weird is going on with ferritin, I will I think it's worth doing an iron panel. But also if the inflammation is that high that it's kind of influencing iron, you know that's another thing to maybe think of like okay why is why is inflammation the C reactive protein so high? So maybe like another avenue that I would go down with somebody but we do want to kind of look at these general labs. And so just a basic lab, if you don't have the ability to order all of these things would be a ferritin. But ideally if we're really wanting to dig in more into what's going on we would run a CBC or complete blood count the ferritin and then the full iron panel which includes serum iron, total iron binding capacity, transferrin saturation and then maybe separately we would do like the C reactive protein just to check for inflammation but I may not always do that one unless I suspect that something's kind of wonky going on with ferritin. So you know those that is essentially what we're looking at what we're testing. And you know I talked a lot about ferritin. I'm not going to dive deep into the other lab labs but um I think ferritin's probably the one that's most commonly used. So I'm going to chat on that. But I think um obviously the other ones I think are more indicative sometimes if we want to dive in more into what might be going on with iron. I've had all these panels done before but I still kind of think for me ferritin has been the most helpful. One thing I do want to mention with the labs is if you go in and you have labs done, you want to make sure if you're taking iron supplement that you don't take it within the few days before because that can kind of do some funky things with the levels. You want to have a few days without the supplement so that you kind of get a real good idea of what's going on with iron. And you don't want to do a really hard workout. Anytime you're going to get labs done, you don't want to do like a really intense workout or like a race the day before you do the labs because that can really kind of cause some weird values not only with iron but with things like kidney function and other things that can kind of set some red alarms. So we want to just give it like do the labs a day after like an easy day. Don't do it after a hard workout or race. Those are just some basic tips for doing labs to make sure that we're not sort of influencing the lab values with either supplements or some sort of influencer like hard workouts and always make sure you're um well hydrated you know you you there's basic things like that don't drink alcohol before just so we can really get a good interpretation of the labs and not have anything really like confounding what might be going on. So kind of there I'm going to dive in next to some really into the food sources of iron because I do believe that food's first and so if you're not iron deficient or you don't feel the need to have an iron supplement, what can we what can we include in our diet to influence iron? What are things that are going to maybe decrease iron availability? How can we increase iron absorption? And so some tips there. And then I'm going to talk a little bit about um supplement strategies. So some of the supplements we might be using kind of what a protocol might be, what supplements to consider um so I'm going to dive into that next. So I hinted at this a little bit during my during the beginning when I was mentioning my own journey and a little bit about foods that are high and not so high in iron or that are more absorbable. And so just a little reminder here that our heme iron is going to be better absorbed. It's more bioavailable and that's going to be predominantly like our red meat sources so beef and bison, maybe some portions of lamb liver is going to be pretty high and dark meat poultry and certain types of shellfish and fish may have some iron in there. Chicken, white meat chicken, like cod, tilapia quite a bit less iron because it's really that darkness of the meat is kind of the heat where the heme is and so that's why red meat is a little bit higher. Those are going to be like the best sources. So if you are able to consume meat or you are a meat eater, trying to consume you know a red meat, bison, beef, dark meat poultry two or three times a week is a good rule of thumb. And also trying to get other sources of iron from more non-heme iron sources as well. If you're a vegetarian or vegan iron athlete it's going to be a little bit harder. So you're going to have to pay more attention to ways to improve absorption, eating those foods more often so having sources of iron maybe even daily or at several meals a day to be able to really get a good amount of iron. So that's going to come from I think we think a lot of like spinach and like leafy greens and that is a good source. If you can cook the spinach and you can get a big old bunch of spinach into a smaller amount that is easier to consume the more iron you're going to get that way. So something to think about beans and lentils tofu have some not a lot but there is some in there pumpkin seeds could be a fairly good source. Fortified cereals might be a really good way to go if you can get like an iron fortified cereal or um something like whole grains like quinoa may have a little bit but none of these sources are going to be extremely high so we just want to make sure we're getting an abundant amount of different high iron non-heme iron sources in there and trying to do what we can to increase absorption. So we're going to help increase absorption there's a couple things we want to consider. We want to eat foods that are high in vitamin C. So what is that? It could be like kiwis, strawberries, peppers, uh broccoli, um like citrus fruit those types of foods are going to be high in vitamin C. So if you compare your meal with something high in vitamin C, you're going to get a little better absorption that way. If not possible, maybe a supplement but I do think food sources are going to be your best bet because when we eat food there's other things that are promoting our ability to absorb it. There are sometimes things that we will maybe that actually inhibit absorption. So we'll talk about that but one really great way is to promote intake with vitamin C. So kind of pairing foods together it could be beef with uh tomato sauce and bell peppers it could be cooked spinach and maybe you add some bell peppers or some tomatoes in there or some broccoli. You could um add uh some make like a big salad with strawberries and pumpkin seeds in there. So just kind of things thinking about ways, you know, a spinach salad with strawberries and pumpkin seeds is an example because you have two uh non-heme iron sources with the vitamin C from the strawberries so just kind of thinking of it that way um pairing those foods another thing you could try if you're an athlete that's vegan or vegetarian is using it's called um well first of all cooking in um iron um cast iron cookware can be a great way cast iron itself is a source of iron so cooking and cast iron cookware can help because you're getting an iron that way and then there's also a product called the looky fish it's like a cast iron a little fish fishy that you put and you cook with it you know use it and put it in while you're cooking and it kind of helps the food absorb more iron that way. So those are options for our for anyone but our vegetarian and vegan athletes I cook a lot in cast iron cookware um it does sometimes depending on what you cook it in or cook with it or use when you're cooking or the food you're cooking I mean it does can leave like a little bit of an irony taste. So there's that I mean that I guess ensures you can taste it so you know you're getting iron. But that's another option too is trying to find ways to kind of get iron in your diet without having to maybe have meat and so cast iron or the little lucky fish uh cast iron uh fishy thing that it's like a shape of a fish and you just add it in when you're cooking those can be great ways to get more iron. Another thing to keep in mind is there are certain foods that actually inhibit absorption. So we don't we don't necessarily want to get obsessive about this but we also don't want to you know maybe actively do things that are going to inhibit our absorption. So things like coffee and teas have something called tannins in there that kind of is what creates that darker color in tea or coffee and that can actually inhibit absorption of iron. It binds and kind of makes it harder to absorb. So we don't want to be you know this is where we don't maybe want to be drinking like coffees and teas all day long and having that with every meal because it might inhibit our absorption of iron, uh calcium so mostly here it's not necessarily I mean you probably don't want to have like a big old bowl of yogurt along with your iron supplement or um have a big glass of milk when you're tak when you're trying to eat something with iron in it. So you want to be a little bit aware of that. But like a little bit of cheese on your salad or something like a little bit of cheese if you're making a pasta dish with me isn't necessarily going to have a huge impact. So we don't want to go get you know too weird about it, but just it's those larger doses of uh calcium and then also like calcium supplements. So we don't necessarily want to take our calcium supplement when we're trying to eat a meal that's high in iron because they compete to be absorbed. So in the gut you'll only be able to absorb a little bit of each because they're competing to be absorbed. So we don't want to have we'd also wouldn't want to take our calcium supplement with our iron supplement because those two will compete and you won't get the optimal absorption of either one. And so just being careful with large portions of dairy and calcium supplements when we're trying to up our iron intake or eat an iron rich meal. Or if we're taking a supplement we don't want those altogether. So just something we want to be thinking of. The other one that may be beneficial is there's quite a bit of or there is some research on a specific probiotic called Lactobacillus planetarium. I think I'm saying that right terum planetarum 299V or LP299V if you want to look that up and it's good research for things like IBS or irritable bowel syndrome but there is some interesting research on this particular probiotic and helping with the absorption of iron and there's some research in children but it's promising I've and there are some supplements that you can find that actually combine iron and um LP299V so one I've tried or used before is gyro formulas ideal bowel bowel support and then there's another good belly is another option and they have one that has both the either the LP299V by itself or the one that combines it with iron. So that might be something you would want to take it with the iron rich food or the supplements but there is for those who have a hard time bringing their levels up that might be something to consider or for our vegetarian and vegan athletes that need a little boost in iron absorption that might be something to consider too so things that help absorption vitamin C that probiotic I was just discussing you know we'll talk a little bit about supplementation and absorption but those are going to be helpful and then avoiding you know large doses of coffee tea or large amounts of calcium. So those are going to be what we really want to make sure we focus on um you know I think supplementation is a big question I get is you know is it important to supplement? Does everybody need to be taking an iron supplement and the answer to that is no. If you don't know what your iron status is I don't generally recommend taking a supplement because it can sometimes cause a little bit of GI upset depending on the supplement a lot of people can experience like a little bit of nausea or constipation so getting the supplement right is important. And iron overload is a concern for certain individuals. So too little is not good like I mentioned too much is not good. Hemochromatosis is a serious condition and so we want to make sure we test the levels before we start supplementing especially if we're going to be doing higher doses of iron. So testing before supplementing trying different forms of iron there are several different forms I remember when I was in college they gave me ferrosulfate elixir it was like it looked like it came in like a chemistry bottle it was like this liquid iron ferrosulfate very hard on the stomach I tolerated it actually fairly well but it tasted awful so what I would do is I would take it I think it was like a teaspoon or two I would put it in a shot glass with orange juice and literally hold my nose and like swallow it down like a shot and it tasted like licking a metal pole. But I did it every day because I was very motivated to bring my iron levels up and perform better and feel better. So definitely something you know you want to think about is the form it's in you know is it going to be tolerable? That particular form can be pretty hard on the gut, like I said. And so sometimes I mean for me it was okay but some people Do you experience stomach pain or constipation with iron? So we want to be thinking about that. Chelated iron is popular, iron bisc bisglycinate is a popular one. I use the thorn iron supplement. There's a lot of different formulations out there, so I do recommend trying if you're if you do need to take iron, trying in different forms. Trying, you know, the the level you're going to be recommended and how much to take is going to be dependent on kind of how deficient you are too. So there's no light blanket recommendation of like, oh, you know, you need to be taking 30 or 60, you know, milligrams. But the but the but one thing to consider is that when you're working out, there is after you're done working out, there is um an increase in something called hebsidin, which is something that inhibits iron absorption. So we don't really want to take our supplement immediately after a workout. We want to sort of spread that maybe later in the day. I tend to take mine before bed or in the evening because that's I'm going to bed, so I'm going to sleep, you know, it's time to absorb it. I'm typically, it's not before I work out in the morning and I'm, you know, would be worried about it causing GI upset. So I always take it in the evening. And one thing you might not also consider is that every time you take a higher dose iron supplement, that in itself inhibits absorption. So when you take a really high dose, there's sort of this mechanism that causes our body, you know, even if you have a deficiency, this is what's so ironic with it, is even if you have a deficiency, if you take a high dose of iron, it actually inhibits the body's bill ability to absorb iron for about 24 hours. So maybe a little longer, depending. So a lot of people recommend taking that supplement every other day. So instead of 30 milligrams daily, maybe 60 or something like that, you know, roughly that amount every other day. And um, that works well for absorption. I think my struggle with that is then I don't remember to take it because it's every other day. So it's hard, you know, unless I put like a reminder in my phone every other day, it's harder for me to remember to take it. So then I'll end up skipping several days before I take it again. And then that's maybe not super helpful either. So you have to kind of think, okay, if I take a little higher dose every day, I'll still absorb some of that. Versus if I do it every other day, but I'm not, I don't remember to take it every other day because it's not a consistent thing in my schedule, then maybe I'm not getting enough. And so you have to kind of think about what would work best for you. But if ideally maybe an every other day protocol is probably better, but you have to, you know, do what works best for you. So we want to make sure we keep that in mind when we're supplementing and you know, working with someone like myself to figure out what works best for you. So I've worked, I've known I've worked with so many different athletes, but you know, I've had athletes, it's been a process where, you know, they're coming in with low iron and we're recommending a certain supplement and it's not really res they're not really responding. And so we're having to try different forms of the supplement or they're having GI issues with the supplement. So it's sometimes just trying to figure out what's the best protocol for each individual athlete. And sometimes I will recommend adding that to 99V, and sometimes um, you know, I might recommend adding a vitamin C supplement or eating foods high in vitamin C with the iron supplement. So it is important to kind of if able to work this through with somebody like a dietitian or somebody who can kind of help you troubleshoot and retesting. So testing before you start supplementation to make sure it's truly an iron deficiency that you're dealing with. And then honestly, I recommend testing every two to three months so that you can see how, you know, if the protocol you're using for supplementing or if you've decided you're going to increase your intake of iron-rich foods rather than supplement to see if that's actually working. Because if you go too long and you're trying this and it's not actually bringing your levels up and you're not feeling better, then you need to know when to pivot and when maybe you need to try a different supplement or to add a supplement. So test, test, it's really important at least to get the ferritin every two to three months and trying different forms of iron. And you just want to make sure that you're timing the supplement out at a good time of day. So it's not right after a workout and not with a calcium-rich meal, and you know, not and maybe every other day. So it does get a little bit complicated, unfortunately. But we want to make sure that you know you're optimizing absorption the best you can. So it does become, it's not so easy as just necessarily taking the supplement. Although if you're taking it and you you, you know, it's better than not taking it, I guess, if you need it. So, you know, if if it's too complicated, just at least taking the supplement so you're getting some iron if you need it. Um, there are some um things that we can do to kind of prevent iron deficiency. As we're as we're thinking through this, I think you could probably think of a few, but one would be just eating iron-rich foods regularly, you know, making sure you're incorporating those foods on a regular basis before you have a deficiency, including adding vitamin C foods, um, avoiding blood donation during heavy training. And I know this is hard for those individuals who do maybe want to help and make a difference. But for athletes, I know, you know, I've ever since college, as when I've been have heavily training, I just try to avoid, you know, losing unnecessary amounts of blood, because for me, I've always had a struggle with low iron. So at this point, I'm not even sure I would be able to donate. I don't know what the threshold is, but it's important to kind of consider that the way the pros and cons of what that might mean in terms of your iron status, you know, for women, monitoring menstrual health, if your periods become irregularly heavy or they are um there's some sort of change in that happening, then we want to make note of that, you know, the heavier the period, the more blood loss there may be, and that can impact our ability or our iron status. Um low energy availability, so just not eating enough in general can impact iron status. So, you know, keeping tabs, making sure we're fueling correctly, scheduling that routine blood work, you know, especially if you're sort of higher risk. So making sure, even if your iron levels are good now, making sure you are checking at least every year, but if not more often than that, to really ensure that you're not missing something, especially if we can catch it pretty early and bring the levels up before there's a deficiency, because once there's a deficiency, it's much harder to get levels to go back up. I mean, working, like I said, with a sports dietitian, if you do need some help with recurrent iron deficiencies or just trying to come up with a good supplement or food protocol for increasing iron, it's always helpful to work with somebody who can kind of help you through that process. So something to consider as well. And just a reminder that, you know, the low iron can impact performance before an anemia. So we don't want to wait until we're iron deficiency, a full iron deficiency anemia. We can see that even when levels are at 30 or below for ferritin. And that is, you know, you again, you could go into the doctor and have a level of 20 and they could say you're totally fine, but you're not, because maybe you're already seeing these symptoms of reduced VO2 max. Maybe your endurance is lower, you're not able to, you know, go as far as you used to, your training quality is starting to suffer, and you're starting to feel like the effort is harder. That could be all signs of um iron, low iron status before you even had a true anemia. If you have a true low like anemia, those symptoms are far worse, like extreme fatigue, inability to really complete workouts, having to stop during workouts. It gets much worse. So trying to catch it earlier is helpful. So let's kind of go through some of myths that I hear. What are some of the things I hear and what's the truth? So the first one is that only women develop iron deficiency anemias. Now, that anemia that is not true. Men can as well. I've seen plenty of men, especially I see quite a bit of cross-country, um, male cross-country runners who come in with low iron. So absolutely men can develop low iron, and it's something that we want to be checking whether we're male or female. Um, the other one I already mentioned, but just to reiterate, if your CBC or complete blood count is normal, your iron is fine. That is not true. If your CBC is abnormal for some of those blood markers like hemoglobinin, hematocrit, it's already, you're already in a deficiency. If most of the time you're checking those, it's gonna be those levels are gonna be fine. So that's why we want to do more of a complete iron panel and a ferritin. Iron stores can be low long before a true anemia develops. And so we want to be checking that. We don't want to be relying on just the complete blood count. Um, just eating a lot of spinach will fix your iron, low iron. That's another myth that yes, spinach has iron, but it's that non-heme iron source. And so it's gonna be important to have a varied diet, and if possible, to consume those meat, red meat products. And if not, you're gonna just have to really be more diligent about where you're getting your iron and adding more variety of foods in to get the iron that you need. And another myth is that more iron is always better, and we have to remember that excess iron can be harmful. So we don't want to just because maybe you do find out you have low iron and you're like, well, I'm just gonna take, you know, 200 milligrams of iron a day, which I guarantee might give you some GI issues, but um, it can be too much. There is a possibility to be taking too much. So we always want to be working with someone if possible to figure out what supplement routine is best. And more is not always better. So rebuilding iron stores can be a process. It can take a while. For someone who has a true deficiency, there can be the option of doing a an iron infusion that is not usually covered by insurance unless someone has a true anemia and it can be costly, like I don't know, maybe $500 out of pocket or more. So it's an option for some people who maybe are truly suffering and have truly low levels, but and that'll bring your levels up very quickly. Um, but that it always has to be guided through a practitioner, a doctor, you know, you would want to go see a physician and see if that is even an option for you. And it it's kind of an uncomfortable thing too, because the iron infusion itself is a little bit uncomfortable, but it's yeah, like I mentioned, it's not always covered. So it may not be necessarily something you could even have done, but that's probably the only way to bring your iron levels up very rapidly. Um otherwise it's is a little bit of a process. So just keeping that in mind, it doesn't happen overnight. Um so let's just kind of do some quick question answers here, just some common questions. So I kind of alluded to this, but um we'll talk, we'll talk through it again. So, how often should runners have their iron checked? Like I said, every two, two to three months if you have a deficiency, but maybe every three to six months if you are, you know, just checking on a regular basis would be um probably more optimal, at least yearly, having those labs done, but a little more often for some of our athletes would be better. Um, so that would be my suggestion. Um, can low ferritin affect marathon performance? Like this is an absolute yes, like as long, again, if it's less than 30, so it's low ferritin for the cutoff, that's generally where I put it. But some people don't feel good, you know, when their levels are in the 40s, even. So kind of keeping that in mind, it's a little bit individual at which point somebody might experience changes in performance. But I generally say like anything less than 30 will probably be affecting your marathon performance. Um, is altitude training a little harder if your iron is low? Yes, because you need more oxygen because there's less oxygen. I mean, so you kind of need more uh to you know breathe more and you're already compromised with low ability, a decreased ability to bring that oxygen to the muscles. So you're even it's gonna be even harder when you're in altitude. You're just gonna struggle even more. So, yes, it does, it is harder to train at altitude and to compete at altitude if you have low iron. Um, should a vegetarian athlete automatically consume an iron supplement? And this is a no. Um, unless you have an iron deficiency, you want to get that checked. Just because you're vegetarian doesn't mean you need to automatically do an iron supplement. I mean you could consider just a multivitamin with iron. So generally that'll be somewhere between 9, 8 to 18 milligrams per day, which is not a high dose, so that could be an option. But I wouldn't go and take like an additional large dose of iron if you don't know whether or not you need it. So don't automatically take it. The only thing I would suggest is maybe just a daily multivitamin with iron that's just got a fairly low level just to kind of cover your bases if you're worried. But it wouldn't be, I wouldn't go out and take an iron supplement if you don't know what your iron stores are. What is the best time of day? And I kind of alluded to this. It kind of depends on your personal factors. Like it's kind of the time of day where you can take it and maybe not have GI side effects and you're not taking it af right after a workout where you're gonna have lower absorption, and maybe not with anything that's high in calcium or you know, the I like it at night too because I drink coffee in the morning, so there's a lot of factors going into that morning, the morning routine that make it hard to take the iron. So I personally like to take it at night, but it's gonna be a little individual as long as you're kind of considering all those things that inhibit or influence absorption. Caffeine doesn't necessarily interfere with iron absorption, so it's not necessarily the caffeine, but the tannins in the coffee and tea that we want to be more aware of. So it's not necessarily caffeine that's inhibiting it, it's the tannins. Um, and why do my iron levels keep dropping despite supplementation? Um, that might be if they're continuing to drop despite supplementation, and you've already tried switching the supplement to another supplement or taking a higher dose, then it might be worth doing a little bit more digging to make sure that there isn't something more serious going on, like some sort of loss of blood through the GI system. So some, you know, that even if you're not noticing that in your stool, like if you're losing blood, you know, that could be something more serious going on. So if you're still like having a depletion of iron stores despite some form of supplementation, or you're even despite high dose supplementation, that is something I think worth a hot a little bit more of an investigation with a physician or a GI specialist because it could mean that something you're losing blood somewhere. And it could, you know, if you can't identify any other place, then it could be through the GI system and making sure, you know, maybe doing a stool sample or there may be more investigation there. And then some people have genetic factors that make it harder for them to absorb iron. So you may want to ask your parents, you know, relatives if they've ever struggled with iron deficiency anemia. There is some genetic factors that can influence that that you may want to explore because I have had people with that situation where there's a genetic piece and they aren't able to get it up with supplements, and they've had to do like iron infusions to get their levels up. And so that may be an in where that may be indicated is in that sort of situation. So things to consider there. That's why we want to test and then retest to make sure that it is going up and there isn't something more serious going on. Um, so I just want to kind of do a few takeaways just to remind iron is essential for oxygen transport and energy production, and that translates into our performance as endurance athletes. Um, we are as endurance athletes at increased risk for iron, low iron, because sometimes the losses that we have for iron are greater than the demand. And so we want to make sure we're balancing that out and we're not using more than we're taking in essentially. Uh so fatigue, lower recovery, declining performance shouldn't be ignored. Of course, there can be other factors that are influencing that, but we want to make sure we are checking if you suspect at all it could be low iron. It's not that expensive. I've gone into my local, I live in Colorado, there's a local lab here. I can go in and ask for a la carte labs. I think I did a ferritin and it was like 30 or 40 bucks just to run a ferritin. Super easy to do. I think I was just out and about already, went to the lab, asked for that a la carte lab. I paid out of pocket and easy peasy. I got it in my like lab results that same day or the next day. So it's so easy. You know, don't need to go through the physician if you don't want to. Um, although I do think it's helpful. You you you can just go in many states, just go order a lab or do it through some of these inside trackers or you know, different lab companies. So don't need to do it through a physician. You know, you can even come talk to me and I'll order a lab for you. You can do that. I'll I can order you labs depending. There's a few states I can't. So focus on an iron-rich diet, optimizing absorption, and um just making sure you're careful with supplementation. Only taking a supplement if you absolutely need to. So hopefully that's helpful. Um trying to think if there's anything else related to iron that I didn't mention, but I think I got most everything. So if you haven't considered iron or maybe you're already struggling, hopefully this has been a helpful review. Maybe there's some tidbits that you learned that you didn't know before. But feel free to reach out, Katie at fuel the number two run.com and send me a message. Uh, ask a question, let me know if there's anything that I missed when it comes to iron or any you know research or things that you're looking at when it comes to iron and supplements and and better ways to absorb iron. I'm always looking for things like that to enhance my knowledge, but don't uh hesitate to reach out. I hope this was helpful little review. And thanks a lot. Bye.

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That wraps up today's episode of the Endurance Athlete Journey Podcast. Endurance sports have a way of teaching us patience, humility, and resilience. Lessons that carry far beyond the workout. Progress in endurance sports doesn't come from shortcuts, it comes from consistency, discipline, and doing the work when it's not glamorous. Wherever you are on your endurance journey, keep trusting the process and honoring the work you put in each day. If today's episode resonated, please subscribe, leave a review, and share it with someone to help on their endurance journey. Don't forget to join the conversation on our social sites to help build and foster a community where we all learn and support one another. We'll be back with more stories and insights from Coach Justin and Katie. Until then, visit the podcast website at the endurance athlete journey.buzzsprout.com for more episodes from the Endurance Athlete Journey Podcast. Have questions or comments about the podcast? Feel free to send us an email at the endurance athlete journey at gmail.com. For all things coaching, visit coachkatie at fuel the number two run dot com and coach Justin at tabula rasteracing.com. Again, thank you for listening to the Endurance Athlete Journey Podcast, and remember to find joy in the journey.