Dealing with iron deficiency
Who is at risk from iron deficiency, and how can you deal with it? This article looks at the measures of iron deficiency, supplements and how to reverse the anaemic trend.

Dealing with iron deficiency

Dealing with iron deficiency

If anaemia was a star sign, your horoscope would probably read like this:

Although you are renowned for your tireless work ethic, boundless enthusiasm and love of monster training loads, something just isn't right. Over the last few weeks, the people closest to you, including the one who holds the watch while you train have seen it too. Do not despair, the ruler of ferrous supplementation is on the rise at the moment and hope is at hand via the intervention of a friendly physician and a small blood sample. Be prepared to take stock, consolidate and take your first steps on the road recovery.

Endurance athletes are one of the key groups at risk of developing iron deficiency

The likely incidence of an athlete demonstrating a true anaemia is really quite low. The problem stems from an increased iron demand that is not balanced by an increased iron intake. Discounting any underlying clinical disorder or recent blood loss, healthy athletes will more than likely demonstrate a normal, but accelerated, iron metabolism.

An athlete suffering from iron deficiency anaemia will feel fatigued, lethargic and may struggle to complete training sessions that previously would have been easily completed. Endurance athletes are one of the key groups at risk of developing iron deficiency. Others include restrictive eaters, vegetarians and female athletes experiencing the blood loss during menstruation. Iron deficiency can be identified from a simple blood test. If iron deficiency is suspected, the key parameters to be investigated include.

Mean cell volume of the cells (MCV)

Reference interval 80 - 96 fl
This parameter describes the average size of red blood cells. Younger Rbc's are much larger in size then the mature cells. Therefore conditions of increased red cell destruction and consequent increased rates of production are associated with increases in mean cell volume. Evidence to date is that elite athletes may have slightly higher mcv's then the sedentary population. It can be raised further in conditions of B12 or folate deficiency and is decreased in Iron deficiency anaemia.

Percentage of hypochromic red cells  

Reference interval up to 4%
This is the percentage of cells with a low haemoglobin content. The greater the number of cells with a cellular haemoglobin content less than 28g/dl. Should an athlete's iron stores be unable to supply the newly produced cells, then the percentage of hypochromic cells will be increased.


Reference interval
Males 30 -300 ng/ml
Females 10 -160 ng/ml

A diminished ferritin count generally reflects that iron stores are being compromised. However, ferritin values can be quite unstable and care must be exercised when interpreting values in athletic populations. Ferritin counts may be increased during response to infections or inflammation.


So the stars predicted it, both you and your coach suspected it, and the physician has confirmed it, you have low iron blood levels, what can be done?

As outlined in the previous two articles, iron deficiency takes time to develop. Initially, it will have become apparent within the immature red blood cells (reticulocytes) before manifesting itself within all the mature red blood cell population. Typically, cells are smaller than normal (microcytic), the iron content (haemoglobin) is low, high numbers are reported hypochromic (pale) and stored iron levels in the form of ferritin are much lower than normal. These results are considered with the specific sensitivities of interpreting blood test results of athletes as discussed in the first article in he series.

iron supplementAlthough iron supplements are readily available over the counter, they should never be taken haphazardly but should be used as directed by your sports physician. There are two types of iron preparations: ferrous and ferric. Some athletes report stomach problems difficulties with oral preparations of iron supplements. These are usually due to this highly reactive metal interacting with the internal environment whilst it is being absorbed. In recent years this situation has been addressed by coating the preparations. This lessens the gastro-intestinal disturbance but unfortunately it does compromise the bio-availability of the complexes and may limit the amount absorbed. Water-soluble ferric compounds are now becoming available, these should overcome this difficulty and enhance the iron delivery.

If your iron stores are seriously depleted then an extended period of supplementation will be required; the length of time will be directed by the physician who will utilise further blood tests to monitor the haematological response. The efficacy of the particular supplement can be quickly ascertained by examining the cellular haemoglobin content of the reticulocytes (newly released cells). Whilst ferritin is often utilized, it must be remembered that it may be affected by a number of factors that must be considered, such as tissue inflammation or infection.

Iron supplementation in the form intra muscular and intra venous injections are generally only utilised when large amounts of iron are required rapidly. Certain intravenous iron preparations can carry risk of serious anaphylactic reactions and as such are rarely utilized outside specific clinical instances. 

What if I eat lots of liver and heaps of spinach?  

As detailed throughout this series of articles, iron deficiency anaemia takes time to develop, unless due to an acute instance of blood loss. It occurs when an increased iron demand is not balanced with an appropriate intake.

This presents some difficulty for those athletes who do not consume lean meats

The iron found in food can be separated into two groups, haem and non haem-iron. Meats, poultry and seafood contain both groups but cereals, dried fruits, vegetables and eggs only contain non-haem iron. The most readily bio-available source is within the meat groupings although the second source, non-haem, represents the majority of our daily iron intake but is poorly absorbed by the body yet. Of course this presents some difficulty for those athletes who do not consume lean meats. Where this is the case, adding vitamin C to a meal (i.e. fruits or juices) will help unlock the iron contained within. Taking vitamin C will also have the same effect when taking iron tablets, and conversely, taking caffeine will inhibit iron absorption.

In conclusion  

Endurance athletes are at particular risk from iron deficiency, which if unchecked may develop into a true anaemia. Add the following factors to your own list:
  • Female athletes (menstruation)
  • Vegetarianism
  • Fad dieting or restrictive eating
  • High impact activities resulting in excessive haemolysis (red cell destruction)
  • High carbohydrate diets with limited flesh food intake.
For more checks on your list, consider the following:
  • Identification of risk factors
  • Increases haem and non-haem Iron sources in the diet
  • Blood tests -Red cell count, haemoglobin, Mean cell volume, ferritin ,Vitamin B12, Folate.
  • Reticulocyte (haemoglobin content) analysis provides an early warning indicator where possible ask for it o be included in the standard profile
  • Do not begin taking iron tablets haphazardly seek advice from your physician
If iron deficiency has just been diagnosed by your physician, action may include:
  • Oral iron supplementation will be probably be initiated by your physician
  • Take supplements in conjunction with some vitamin C to aid absorbtion
  • Avoid caffeine which will inhibit absorbtion from both your diet and any supplements
  • Repeat haematological profiles to monitor the efficacy of the supplementation
  • Any masochistic urges to eat solely spinach with every meal for the next six months should be firmly suppressed.
  • Finally, any plans for a spell of altitude training should be placed firmly on the back burner, the next article will explain why!


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