The more I pursue my athletic career, the more I find myself looking for ways to understand my body better. Those marginal gains really do add up and one of the key changes I have made over the last few years is the way in which I understand my own body and how it functions. I think back to when I was 80kg, my diet lacked in nutrients, my sleep was poor and I didn't exercise, ever. When I look back at that time I am surprised my body even continued to function as it did, but I just think I didn't know any better. The more I get to truly know myself and how I respond to different things, the more I am able to balance recovery and training and optimize my performance (That's not to say I am perfect, I still have so much to learn, but I find that prospect quite exciting). The below are my opinions and experiences and I want to start by saying that each body is so individual so my result might not be the same for you. Please make your own decisions based on your own body!).
So, a year ago I was put in contact with Tim and Heike down at the Iron Suites, Singapore. The Iron Suites is a medical clinic focusing on the management of iron deficiency. They invited me down to take an iron test as they had seen how much I was running and training and they thought my levels might be quite low. I arrived at the office and was met by the friendliest team of staff. If you know me you will know that I am (or was) pretty terrified of needles and as a result, I get myself in quite a state when I am faced with the prospect of a blood test. But, they had two nurses there to support me, Ethel took my blood while another lovely nurse provided some much needed moral support and they took my blood without any stress and I was reassured beyond belief. Looking at the poster on the wall that listed the symptoms someone with iron deficiency might be facing, (see below) I was pretty convinced I wouldn't have a problem. I was wrong. Within two days I had my results and a phone call told me that my ferritin levels were so low that I was classed as being 'absolutely deficient in ferritin.'
What is Ferritin?
Iron is important because it is a key part of hemoglobin. We need hemoglobin to carry oxygen to the tissues in our body. If you don't have enough iron then your body won't be able to make enough hemoglobin and this can then affect the efficiency and ability of your muscles, something that is pretty crucial if you are engaging in exercise and particularly if you are looking to perform to a high level. Ferritin is a protein that stores iron, releasing it when your body needs it. Measuring ferritin is a valuable way of determining the body's total iron stores and this level can still be low even if your iron level is normal (the iron level in our blood can be really affected by our diet, e.g. if you had a steak before taking the blood test). Different test centers use different reference ranges, but at the Iron Suites, they class a healthy ferritin level as between 30 - 300 ng/ml. Mine was just 18 - hence being absolutely deficient.
Upon finding this out, I went back for a consultation with the doctor. He talked me through what my results meant and explained my options. There are a number of ways in which you can increase your iron levels: through your diet, through iron tablets or through an iron infusion. Seeing as my diet is mostly plant based, that didn't seem like a possible way to get my levels back up as high as I needed them. To put that into context, Insel et al 2003 found that heme iron (shellfish, red meat, poultry, and fish) is absorbed at around 15-35% whereas only around 2% of the iron from cooked spinach (non-heme iron) is absorbed and around 7% from soybeans.
Because I was so low they suggested an iron infusion to bring my levels back up as quickly as possible. My needle fear almost got the better of me, but again, a room of kind nurses got me through and the procedure really is quite pain free. It begins with a saline flush into the vein in your arm and then they slowly administer the iron (while you get to sit in a very comfy chair) once that is done, the team will keep you there for 30 mins to just monitor that all is okay (a great time for a chat or nap - I'm a talker!) and then you're done. In terms of the difference I felt - the change in my energy levels was very noticeable. In terms of performance, I flew off to the UK the next day so it was hard to say for sure due to the change in weather but I certainly hit a number of PBs and felt very happy with my race performance that summer.
Why Are Athletes More At Risk?
There are a number of reasons why as athletes we might be more susceptible to low iron levels. Firstly, intense exercise and sweating can cause you to lose small amounts of iron (I do plenty of sweating in Singapore!). Furthermore, when you run, the repeated pounding against the floor causes the destruction of cells in your feet which causes the iron to breakdown - hence why we see iron deficiency more in endurance athletes. These are issues that can affect both men and women but when you add all of this to that a monthly period, it isn't surprising why female athletes are much more at risk of becoming iron deficient if they are not monitoring their levels. One study found that up to 90% of female endurance athletes were deficient in iron (*1) If you are plant based then the numbers you are getting from your diet will be minimal and you will end up losing more iron than you are taking on.... cue iron deficiency.
So What Next?
As often happens in life, having the infusion became my new normal and I soon stopped thinking about it. I was tested 6 months later and my levels had risen from 18 to 98 so I was in a healthy range and I continued to train hard and work with The Stretch Clinic to understand and listen to my body more. Fast forward to August this year and I have been feeling pretty rubbish. Putting it down to low energy levels from work and the stress of relocation, I didn't even think about my iron levels and actually went to the doctor to be tested for dehydration. When these levels came back normal and I was explaining this to a friend who used to train a number of top athletes, he asked when I had last had my iron tested. Suddenly that made total sense, I pulled up the symptoms and I had most of them (to the point that I was shocked that the doctor had not thought to test my levels when I went in - he tested me for Type 2 diabetes but not that....). I booked in again to the Iron Suites and got an appointment to have a blood test the next day. Within 24 hours I had my results and I was, unsurprisingly, iron deficient again. My levels had dropped from 98 to 26 in a year and looking back I didn't do a very good job to prevent it. I wasn't focused on getting iron into my diet and I couldn't even remember the last time I had eaten red meat, but I had still been training hard, sweating plenty and running more than I ever had before, so I guess it was no surprise that my levels were low again. I mulled over the fact that I did not feel the symptoms the first time but did the second and I think I put it down to becoming much more aware of my body. I now know when to look for signals that don't feel right and I have a training routine that I monitor which allows me to assess and reflect on how my body is responding during each workout and on recovery days.
Ethel is probably the best nurse I have ever come across.
I decided to get another infusion and within a few days the daily headaches had lifted, my ability to concentrate was back (thank goodness!) and my energy levels had increased (I no longer felt the need for a nap at 2pm). As I write this it has not been long enough for me to have the follow up test but I have no doubt my levels will be back up again. Obviously, this is very much my personal experience and it might not be suitable or relevant for all but I realised that I was uneducated about the impact that being an athlete and training hard can have on your iron levels so I figured there might be a few people out there who were also unaware. In terms of marginal gains, if your body is unable to properly carry oxygen to the tissues and muscles you are using it is obvious to see how this will impact your training and also your overall health. So I would say, if you're in a place where you feel that you have some of the symptoms or you're just interested to see how your body is currently processing iron - go and get yourself tested - you might be surprised with what you find.
If you have had your own experience with iron drop a comment below, I would love to hear other people's stories.