The Athlete’s Kitchen: Athletes, Iron & Anemia

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My teammate eats ice chips like crazy. Isn’t that a sign of being anemic?
Something must be wrong with me. I get out of breath just walking up a flight of stairs…
Should I eat lots of spinach to boost my iron intake, given I’ve stopped eating red meat?

By Nancy Clark MS RD CSSD — Many of today’s athletes are eating little or no red meat (beef, lamb), which is one of the best sources of dietary iron. These athletes are simultaneously consuming less iron. Iron is a mineral found in the hemoglobin molecule inside red blood cells. It helps transport oxygen from your lungs to your muscles.  Iron deficiency contributes to anemia, with symptoms of unusual fatigue during aerobic exercise—or even when climbing a flight of stairs. Athletes with anemia may complain about light-headedness, weakness, poor performance, and yes, a desire to chew on ice! While fatigue can also be caused by lack of sleep, depression, stress, and calorie restriction, fatigue due to an iron deficient diet is common.

Iron deficiency anemia is more prevalent among athletes—in particular, athletes in running and endurance sports—than among the general population. That’s because athletes lose iron with heavy sweating, blood loss in urine or via the intestinal tract, and damage to red blood cells caused by footstrikes while running. Female athletes lose blood via monthly menstruation, hence women are more prone to becoming anemic than are men. This study shows just how prevalent the problem is: A survey of 277 everyday runners (~60% females; average age, 40 years) participating in the Detroit Free Press Half- or full Marathon indicates ~50% of the women and 15% of the men had clinical iron deficiency. 15% of the women and 3% of the men had severe iron deficiency. Just think how much faster these athletes could have run!

What to do

If you think you might be anemic, get your blood tested to rule out anemia (and remeasure it in 6 to 8 weeks after treatment). The diagnostic criteria are:

  • hemoglobin (the iron-containing molecule within the red blood cell) less than 120 (female) or 130 (male) g/L
  • ferritin (a marker of iron stores): <12 ng/mL (Ferritin should be >30-40, if not higher),
  • transferrin saturation, <16%

Preventing and/or resolving anemia

If you limit your intake of iron-rich beef and lamb, be sure to consume alternate sources of iron, such as dark-meat chicken or turkey (legs, thighs), tuna, or salmon. About 40% of the heme-iron in animal protein is absorbed, as compared to only 5% of the non-heme iron in plants. Don’t count on plant sources of iron such as almonds, spinach, lentils, beans and grains to satisfy your iron needs! Only about 2% of  the iron in spinach might get absorbed. Despite Popeye’s claim that spinach made him strong to the finish, spinach is a poor source of absorbable iron. Combining heme-iron in animal protein with non-heme (plant) iron optimizes absorption. Hence, add some tuna to your spinach salad, turkey to lentil soup, beef to chili.

While lentils, almonds, and chick peas are high in iron, the body has trouble absorbing iron from plant-based sources. Include fruit or other foods high in vitamin C to help improve absorption.. Photo by Dave Iltis

If you are an athlete who “eats clean” and minimizes your intake of “white foods” (such as white bread, pasta and rice), take note. Refined grains are generally enriched or fortified with iron. Hence, eliminating enriched white bread and other refined grains reduces your intake of iron (as well as other added nutrients). The US Dietary Guidelines recommend eating at least half your grains as whole grains. (This is not a compromise based on the assumption Americans would never eat all whole grains). Enriched white pasta and breads do offer important nutrients!

A salmon and spinach salad is a good source of iron. Combining heme-iron in animal protein with non-heme (plant) iron optimizes absorption. Photo and food by Dave Iltis

Enriched breakfast cereals such as Cheerios, Grapenuts, and Kellogg’s Raisin Bran are good sources of iron. (In comparison, “all natural” cereals, like granola or Puffins, have no additives. That means, they have no added iron.) To enhance the absorption of the iron in enriched cereals, include a source of vitamin C with the meal — such as an orange or orange juice, a clementine, or some strawberries.

Cheerios and other enriched cereals are a great source of iron, better than many “all natural” cereals. Photo by Dave Iltis

Research indicates iron tends to be absorbed better in the morning than in the evening. This is due, in part, to the daily fluctuation of the hormone hepcidin. Hepcidin hinders iron absorption from the intestinal tract and is a key regulator of iron absorption. Hepcidin increases after exercise, triggered by exercise’s inflammatory response. Hence, to optimize your iron absorption, pay attention to when you eat iron-rich foods or take an iron supplement in relation to when you exercise. A good time to consume iron or iron supplements is with an iron-rich breakfast either before or shortly after a workout, but NOT 3 to 6 hours afterwards, when hepcidin peaks. This timing will optimize iron absorption as well as tolerance, given iron supplements are better tolerated when taken with food.

Iron supplements

If you are anemic, you want to boost your dietary iron intake. You will also need to take supplemental iron to correct the deficiency. Do not self-prescribe high doses of iron supplements.  Your doctor should prescribe the dose best for your body. Taking too much iron puts some athletes at risk of iron-overload, which is dangerous.

Iron supplements may be needed by some athletes. Photo by Dave Iltis

Supplements come in two forms: Ferrous iron (gluconate, sulphate, fumerate) and ferric iron (citrate, sulphate). Ferrous is better absorbed from the gut, but ferric iron settles better in the gut. Some athletes find iron supplements contribute to nausea and constipation. If that’s your case, you want to experiment with different brands to find the supplement your  body tolerates best. Slow-release ferrous sulphate and ferrous bisglycinate are popular choices.  Taking an iron supplement every other day is as effective as taking it daily.

The bottom line

To iron out performance problems such as needless fatigue, be sure your diet supports your athletic goals. A registered dietitian (RD) who is a certified specialist in sports dietetics (CSSD) can teach you how to consume an optimal diet that helps you be strong to the finish (with or without the spinach)!

Reference

  • Kohler L et al. Prevalence of iron deficiency in endurance runners: a cross-sectional study of the Detroit Free Press Marathon and Half-marathon athletes. Blood (2022) 140 (supplement):11074-11075
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