Latest / Find Your Edge: Training, Nutrition + Longevity for Endurance Athletes / Iron Deficiency in Endurance Athletes: Signs, Testing & Treatment Ep 150

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Iron Deficiency in Endurance Athletes: Signs, Testing & Treatment Ep 150 · Find Your Edge: Training, Nutrition + Longevity for Endurance Athletes

• 0:38
  Coach Carlie: All right, welcome back to the Find Your Edge podcast.
• 0:40
  Coach Carlie: I'm your host, Coach Chris Newport, and actually today I'm not your host.
• 0:44
  Coach Carlie: I am handing the reins over to Emily Q because she has done an interesting project for school and came across a researcher.
• 0:54
  Coach Carlie: So I'm gonna let you take it from here, Emily, and go for it.
• 0:59
  SPEAKER_00: Thanks, Chris.
• 0:59
  SPEAKER_00: I'm excited to act as your pseudo-host today.
• 1:03
  SPEAKER_00: Yeah, so for my master's capstone project at UNC in the Nutrition Dietetics program, we were tasked with picking a public health problem and making an intervention for it.
• 1:15
  SPEAKER_00: So the one that I picked was iron deficiency anemia in adolescent female athletes.
• 1:21
  SPEAKER_00: And in my research for that project, I came across some of Dr.
• 1:26
  SPEAKER_00: Corey Dugan's research and found it super helpful for my project.
• 1:30
  SPEAKER_00: So I decided to reach out to see if he'd want to pop in as a guest speaker, and here he is.
• 1:36
  SPEAKER_00: So I'm really excited about this collaboration.
• 1:39
  SPEAKER_00: So, Corey, please just tell us a little bit about yourself and how you came to do this research.
• 1:47
  SPEAKER_02: Uh, thanks so much for having me.
• 1:50
  SPEAKER_02: I came to do this research.
• 1:52
  SPEAKER_02: I I'm from Western Australia, and I did my undergraduate degree in sport and exercise science at the University of Western Australia.
• 2:01
  SPEAKER_02: And I was very passionate about exercise.
• 2:04
  SPEAKER_02: That kind of led me down the research path.
• 2:07
  SPEAKER_02: And uh my PhD supervisor was an endurance athlete researcher, and iron deficiency being as prevalent as it is in that population became essentially the the topic of my PhD project, which was looking at iron deficiency in a variety of different contexts, mostly a female athlete setting.
• 2:31
  SPEAKER_00: Right.
• 2:31
  SPEAKER_00: That's well, I'm not going to say it's wonderful, but it's wonderful for our purposes today because that's exactly what we're all about.
• 2:37
  SPEAKER_02: So it's always it's always tough.
• 2:40
  SPEAKER_02: It's always tough to have, yeah, to to give the intro and then say, you know, that it's fantastic to research this area.
• 2:46
  SPEAKER_02: However, you know, if we had a perfect world, no one would be iron deficient.
• 2:51
  SPEAKER_00: Yeah, but unfortunately, here we are.
• 2:54
  SPEAKER_00: So start off, start us off with some of the basics here, Corey.
• 2:57
  SPEAKER_00: So why are endurance athletes at such high risk for iron deficiency?
• 3:02
  SPEAKER_00: There's a lot of reasons, I'm sure.
• 3:04
  SPEAKER_02: There there are several.
• 3:05
  SPEAKER_02: Exercise, specifically endurance exercise, like running as a as an example, is uh a mode that causes iron loss.
• 3:15
  SPEAKER_02: So you lose iron during exercise through a variety of different mechanisms.
• 3:20
  SPEAKER_02: Gastrointestinal bleeding, uh, when you sweat, foot strike, hemolysis.
• 3:26
  SPEAKER_02: So if you're running and when your foot hits the ground each step, you can you do destroy red blood cells with that strike.
• 3:36
  SPEAKER_02: Some of that iron does get recycled though.
• 3:39
  SPEAKER_02: However, these are all factors that go into play when it comes to uh looking at iron status in endurance athletes.
• 3:47
  SPEAKER_00: Can you tell us a little about hepcidin and how that affects all this too?
• 3:53
  SPEAKER_02: Yeah, definitely.
• 3:54
  SPEAKER_02: So I only touched on iron loss during exercise, but it's a fantastic point that another avenue for susceptibility to iron deficiency from exercise is the absorption block, which is hepsidin.
• 4:08
  SPEAKER_02: Hepsidin as the master regulator of iron status in the body.
• 4:14
  SPEAKER_02: So if your hepsidin levels are high, then you have a low iron absorption capacity.
• 4:22
  SPEAKER_02: And in exercise or endurance exercise, you have a really big inflammation response and hepsidin spikes.
• 4:31
  SPEAKER_02: We see very high uh levels of hepsidan during high levels of inflammation.
• 4:36
  SPEAKER_02: So after exercise and specifically endurance exercise, we see that rise in hepsidan, and then uh accordingly you see that decrease in iron absorption.
• 4:47
  SPEAKER_00: Right.
• 4:48
  SPEAKER_00: So a lot of factors stacked against us, endurance athletes here.
• 4:52
  SPEAKER_02: Yes, and that's that's not even considering the uh if if we were to look at female athletes particularly, which was uh the topic of my PhD, there's just a whole nother dimension of factors to consider in in this context.
• 5:10
  SPEAKER_00: Yeah, can you tell us a little bit more about some of these additional factors?
• 5:15
  SPEAKER_02: Well, we already have the increase in iron loss from exercise.
• 5:20
  SPEAKER_02: However, in a woman's health perspective, we also have iron loss from menstruation if the athlete we're concerned with is regularly menstruating.
• 5:31
  SPEAKER_02: We also have increased iron demand for that reason.
• 5:35
  SPEAKER_02: And additionally, if it's a younger female athlete, we have increased iron demand during adolescence.
• 5:42
  SPEAKER_02: And all of these things, uh again, they all just keep on adding to, I suppose, the list of things that can make you susceptible to iron deficiency.
• 5:51
  SPEAKER_02: And if you're, you know, if you're someone that has a lot of these things ticked off, you it's just very likely that you're not only at risk, but since it's very normalized, you can definitely experience it without noticing it.
• 6:04
  SPEAKER_00: Wow.
• 6:05
  SPEAKER_00: Absolutely.
• 6:06
  SPEAKER_00: So, with all that considered, if you're out there and you're a female endurance athlete listening to this, you might be thinking, how do I know if I'm deficient in iron?
• 6:16
  SPEAKER_00: Do you have um short lists of the signs and symptoms that you should be looking for?
• 6:23
  SPEAKER_02: Yeah, this is where it gets this is where it's difficult as well.
• 6:26
  SPEAKER_02: So a lot of stuff I'll I'll talk about is um, I suppose, another dimension adding to why this issue is so prevalent and so underrecognized.
• 6:37
  SPEAKER_02: That a lot of the symptoms associated with iron deficiency, namely the common most common ones are fatigue, brain fog, or difficulty concentrating, restless legs, difficulty falling asleep or decreased recovery, all of these things, right?
• 6:54
  SPEAKER_02: They're not necessarily like if you were to experience any one of those things, you're not immediately going to attribute it to iron deficiency.
• 7:02
  SPEAKER_02: It could be several other things at play there.
• 7:07
  SPEAKER_02: So they're not normalized, they're not specific to iron deficiency, these symptoms, which which I think makes it go uh underrecognized.
• 7:16
  SPEAKER_00: Right.
• 7:16
  SPEAKER_00: And then a lot of people will attribute that to like normal training load.
• 7:20
  SPEAKER_00: And when you're in a you know, intense training cycle, you're bound to feel fatigued, you're bound to feel, you know, drained.
• 7:27
  SPEAKER_00: So by the time you feel like it's the symptoms have gotten bad enough to go check it out, it's probably you you've probably got like really depleted and iron.
• 7:38
  SPEAKER_02: Yeah, and it's just a repetitive cycle and it just keeps on almost feeding itself.
• 7:43
  SPEAKER_02: And then you can see uh contextually, if it's not caught, then you know, the perspective that coaches might have are athletes not trying hard enough or athletes not putting enough effort into recovery.
• 7:57
  SPEAKER_02: And then, you know, there's even other things to consider there.
• 8:01
  Coach Carlie: I've even heard of to add on to the list of potential symptoms like heart palpitations, almost like, is there something wrong with my heart?
• 8:09
  Coach Carlie: Had is that part of some of the symptoms that you've seen?
• 8:13
  SPEAKER_02: Yes, yes, definitely.
• 8:14
  SPEAKER_02: There was uh a list of 20 or 30 symptoms I could have listed there.
• 8:18
  SPEAKER_02: I just did the um the the most common, but yes, heart, heart palpitations, um, hair loss, brittle nails, cold intolerance.
• 8:28
  SPEAKER_02: A really interesting one, uh, it's called PICA, which is the craving of non-nutritious substances.
• 8:37
  SPEAKER_02: The most common ones I've seen in the US and Australia is ice, so craving ice or paper.
• 8:45
  SPEAKER_02: I've spoken to uh professors all over the world.
• 8:48
  SPEAKER_02: I've been very fortunate.
• 8:50
  SPEAKER_02: And the one that I heard recently at a conference was uh in South Africa there is Pika in the desire to consume clay.
• 9:01
  SPEAKER_02: And then additionally, there's the the smell of of burnt rubber or or petroleum.
• 9:08
  SPEAKER_02: So these are all things that I'm learning as well as I you know develop my research and and get to go to conferences and stuff, and I find it, I find it so interesting.
• 9:17
  SPEAKER_00: That is, yeah, I've never heard of, well, I've heard of pika.
• 9:20
  SPEAKER_00: I've never heard of the smell of burnt rubber or anything like that.
• 9:25
  SPEAKER_00: So super good to know.
• 9:27
  SPEAKER_00: I guess if you if you're not experiencing, or maybe if you're experiencing some of the more like general symptoms that you can't really attribute to iron right away, if you go into like the doctor to get labs done and see and try to like assess your iron status, what are the things that you should you want to be looking for?
• 9:46
  SPEAKER_02: Yeah, great question.
• 9:48
  SPEAKER_02: Straight off the bat, it's important to screen athletes, as as you know, any coach would know.
• 9:55
  SPEAKER_02: And female athletes specifically, there's a lot of research out there to endorse the idea that they should be getting their iron checked relatively consistently.
• 10:05
  SPEAKER_02: Now, the issue when you go to just a general doctor's appointment and you get bloods done is that you're not actually having your iron assessed per se.
• 10:17
  SPEAKER_02: A full blood count doesn't uh include any iron-specific panels.
• 10:24
  SPEAKER_02: The one that you can look at in a full blood count is your hemoglobin level.
• 10:30
  SPEAKER_02: However, looking at that and interpreting iron status from that is like reading the last page of a book and trying to understand the entire book in its context.
• 10:41
  SPEAKER_02: It's the it's the final it's the final variable to fall through that iron deficiency cycle.
• 10:48
  SPEAKER_02: So if I was a coach and I'm wanting to screen a female athlete, I would definitely have them ask for iron studies when they're going to have a blood test.
• 10:58
  SPEAKER_02: And then that gives you a range of specific biomarkers that you can look for.
• 11:03
  SPEAKER_02: And some of the most common ones are ferritin, transferrin saturation, iron binding capacity.
• 11:11
  SPEAKER_02: And these are all things that you can consider in in the context of iron deficiency for a female athlete.
• 11:18
  SPEAKER_00: Okay.
• 11:18
  SPEAKER_00: So what you're saying is that like hemoglobin, it can be indicative of iron deficiency, but more likely than not, like if you're iron deficient, you still might have a normal hemoglobin.
• 11:31
  SPEAKER_02: Yes.
• 11:32
  SPEAKER_02: I had a call, I actually looked over a colleague's blood tests this morning.
• 11:36
  SPEAKER_02: She's uh she does a lot of cycling, and her hemoglobin was 13 and a half, so 13.5 or 135 uh grams per liter, which is in in the healthy range, and her ferritin was 7.5.
• 11:51
  SPEAKER_02: So what what that tells me is that she's on the way to anemia.
• 11:56
  SPEAKER_02: So you can think of it as almost like a stepping ladder.
• 12:00
  SPEAKER_02: So at the start, you have optimal iron stores and normal hemoglobin, and then as you lose iron stores, you still have that leftover reserve to be able to make red blood cells and hemoglobin.
• 12:17
  SPEAKER_02: But it gets to a point where if the ferritin drops so much that you're not able to make red blood cells and hemoglobin, then the hemoglobin will drop.
• 12:28
  SPEAKER_02: And that is that that is the end stage of iron deficiency, which is iron deficiency anemia.
• 12:34
  SPEAKER_00: All right.
• 12:35
  SPEAKER_00: So we want to catch this before it gets to that point.
• 12:39
  SPEAKER_00: So my next question is what are the optimal levels of ferritin that endurance athletes should be aiming for?
• 12:47
  SPEAKER_00: Because I um in college, actually, I was a rower for a while.
• 12:53
  SPEAKER_00: And I remember going through a period, like maybe like a few weeks or maybe like a month, a month and a half of feeling particularly fatigued.
• 13:02
  SPEAKER_00: So I went in to go get my iron tested.
• 13:06
  SPEAKER_00: And when I got my results back, I don't think my ferritin was that, was that bad.
• 13:11
  SPEAKER_00: Like it was showing up fine, like within normal limits or whatever.
• 13:15
  SPEAKER_00: But the doctor there told me that ideally they should be higher for an endurance athlete.
• 13:21
  SPEAKER_00: So can you elaborate a little bit on like how much higher?
• 13:25
  SPEAKER_02: Yeah, it's um if you were to ask if you were to ask any researcher that I feel like that'd all give you a different answer.
• 13:31
  SPEAKER_02: And the optimal ferritin level is something that's uh debated, it's been debated for decades.
• 13:40
  SPEAKER_02: I try to stay away from that debate specifically.
• 13:43
  SPEAKER_02: And I always come back to the sports science principle of individualization.
• 13:49
  SPEAKER_02: So if you're a coach and you're screening female athletes, it's really important to think about it contextually.
• 13:56
  SPEAKER_02: So a single ferritin measurement doesn't really tell you much.
• 14:00
  SPEAKER_02: It is the best indicator we have of iron stores, however, not always.
• 14:05
  SPEAKER_02: So as I said, high inflammation um changes hepsodin, it also changes ferritin.
• 14:12
  SPEAKER_02: So that's an important consideration.
• 14:14
  SPEAKER_02: The other consideration, as I was saying, is the single measurement.
• 14:18
  SPEAKER_02: So what's really important is to measure it over time, to look at the delta or the change in ferritin over time.
• 14:24
  SPEAKER_02: So if you're in an optimal iron status state, then it's important to measure it over the course of the season or the periodization plan, and you can track changes in iron status with you know changes in exercise, performance, competition, all of those things.
• 14:50
  Coach Carlie: Although is there at least a number that we are can all agree on that's in the toilet?
• 15:01
  Coach Carlie: Less than 15, less than 10?
• 15:03
  Coach Carlie: Like what or or would you just say it's context of the athlete, kind of like what you were indicating?
• 15:10
  SPEAKER_02: I the World Health Organization defines it as less than 15.
• 15:15
  SPEAKER_02: I've seen people uh pass out from iron deficiency with a ferritin higher than that.
• 15:24
  SPEAKER_02: The Australian Medical Association has a ferritin less than 30.
• 15:31
  SPEAKER_02: Here in the US, I've seen a variety of different levels.
• 15:35
  SPEAKER_02: I think it's pathology uh specific.
• 15:38
  SPEAKER_02: So I've seen levels from 7.5 all the way up to 35.
• 15:44
  SPEAKER_02: I think that as I said, I'll try and stay away from the optimal ferritin debate, but there is new research out in the last few years that I've found really interesting because it doesn't just these these thresholds come from or have come from taking a population sample and saying, okay, we have this sample, this is the average ferritin, so someone is iron deficient if they're two standard deviations away from the optimal, optimal average.
• 16:16
  SPEAKER_02: What this new research is looking at is okay, we're looking at it physiologically.
• 16:21
  SPEAKER_02: We're not just taking uh a sample, a population sample where looking at the cellular level, when does the body call for more iron?
• 16:30
  SPEAKER_02: When is it that some of these biomarkers change as we are losing our ferritin?
• 16:36
  SPEAKER_02: And some of those have come back with um a ferritin of less than 25.
• 16:42
  SPEAKER_02: And there was another research article looking at the changes in hepsidin, and that was a a ferritin of less than 50.
• 16:51
  SPEAKER_00: Wow.
• 16:52
  SPEAKER_00: That's higher than I would have thought.
• 16:55
  SPEAKER_02: Yeah, it was a really good research paper.
• 16:57
  SPEAKER_02: I I just can't remember the um the author's name, but yeah, it was it's definitely worth a read.
• 17:03
  SPEAKER_02: It it suggests that hepsidin begins to decrease before you know anyone would catch it in a standard blood test.
• 17:11
  SPEAKER_02: And that's you know, it it the the standard blood test for female athletes, it's it's not set up to catch it.
• 17:17
  SPEAKER_02: So it's really important to understand that and then, you know, know what it is you should be looking for in terms of screening.
• 17:27
  SPEAKER_00: Okay, very interesting.
• 17:29
  SPEAKER_00: So you've gone to the you've gone to the doctor, you've gotten your labs, you've and it turns out looks like you're deficient in iron.
• 17:38
  SPEAKER_00: So what are the steps you should be taking after that to get in some more iron?
• 17:43
  SPEAKER_00: Because Chris was telling me yesterday about somebody that was super low in iron and was like, okay, so do I need more spinach?
• 17:52
  SPEAKER_00: And it's like, man, if you're at the point of like anemia or borderline anemia, like more spinach isn't going to save you.
• 18:00
  SPEAKER_00: So what what what would you suggest as to get that iron up?
• 18:06
  SPEAKER_02: No, you're right.
• 18:07
  SPEAKER_02: You're definitely, definitely correct there.
• 18:09
  SPEAKER_02: The the standard pathway to increasing your iron status depends on, firstly, you know, what your current levels are.
• 18:17
  SPEAKER_02: If you're at a suboptimal level, let's say, then you potentially have the ability to correct it with dietary intervention only.
• 18:27
  SPEAKER_02: And that's always that would be always my first point of call if I was if I was the coach.
• 18:33
  SPEAKER_02: However, if your iron status is in one of those deficiency categories, then changing it with the diet's going to be very difficult and it will take a a long time.
• 18:45
  SPEAKER_02: So that's where individuals might consider an iron supplement.
• 18:50
  SPEAKER_02: So the the first line of call there would be an oral iron tablet.
• 18:55
  SPEAKER_02: And if you're in that iron deficiency anemia category, then oral iron tablets probably aren't going to bring ferritin up very much.
• 19:05
  SPEAKER_02: And I would say within the first six months, and if that, so that's where um intravenous iron infusions are typically used.
• 19:15
  SPEAKER_02: But I've also seen that intravenous iron used in in stage two as well.
• 19:20
  SPEAKER_00: In that just deficiency category before progressing to anemia, you mean?
• 19:25
  SPEAKER_02: Yes, iron deficiency, non-anemia.
• 19:28
  SPEAKER_00: Okay, got it.
• 19:30
  SPEAKER_00: Typically, if you're in that second camp, I guess the deficiency, but not anemia, if you start taking oral iron supplements, uh, how long do you usually see that it takes before uh you start to see uh improvements in your ferritin?
• 19:46
  SPEAKER_02: Uh it would change depending on the individual, the type of iron that you're consuming, and then specifically the the way you're consuming it and with some other characteristics or factors.
• 20:01
  SPEAKER_02: But I would say that it would be months in in the months, not days and not weeks.
• 20:07
  SPEAKER_00: Alright, months, I see.
• 20:08
  SPEAKER_00: Can you tell us more about the different types of iron supplements out there?
• 20:13
  SPEAKER_00: There's there's a lot of names and a lot of forms, so just want to clear the air.
• 20:19
  SPEAKER_02: As someone that doesn't have an MD, I can't necessarily come out and say this one's better than this one.
• 20:25
  SPEAKER_02: So nothing here is medical advice, just a disclaimer.
• 20:30
  SPEAKER_02: Um but yeah, the the standard iron tablets that you see or are prescribed are elemental iron.
• 20:38
  SPEAKER_02: It's non-heme, so it's it's tough to absorb.
• 20:42
  SPEAKER_02: So you really try, you really need to try and have strategies in place that would um improve your absorption rate.
• 20:49
  SPEAKER_02: Now we know from previous research that things like vitamin C are very beneficial to iron absorption.
• 20:56
  SPEAKER_02: So some strategies an athlete can can do is having it in the morning with a glass of orange juice.
• 21:03
  SPEAKER_02: We also know that things like coffee and tea and some um oxidants are are really big inhibitors of iron absorption.
• 21:12
  SPEAKER_02: So avoiding yes, calcium.
• 21:15
  SPEAKER_02: That was yeah.
• 21:17
  SPEAKER_02: So those things are important to avoid before taking the iron supplement.
• 21:22
  SPEAKER_02: And we said before about exercise having that increased hepsodin response.
• 21:26
  SPEAKER_02: So that kind of shuts the door on it as well.
• 21:29
  SPEAKER_02: So you should try and avoid taking it in and around exercise, especially post-exercise.
• 21:36
  SPEAKER_00: All right, good to know.
• 21:38
  SPEAKER_00: So that's the the timing is really crucial.
• 21:42
  SPEAKER_00: And Chris and I just did a podcast on bone health uh earlier this week.
• 21:47
  SPEAKER_00: And if you're somebody who's trying to make sure you're getting in enough calcium and vitamin D for your bone health, but then also trying to get in enough, get in your iron supplements and all of that, you really have to like start to strategize and plan out when you're taking what.
• 22:03
  SPEAKER_02: Yes.
• 22:04
  SPEAKER_02: And I and that I think is it's something that if you were to go to a general practitioner, then you know that they would they would prescribe calcium and iron.
• 22:16
  SPEAKER_02: But in terms of exercise performance, you would need to consider so many other things in terms of your strategies around timing and consumption because it's going to have a big impact.
• 22:25
  SPEAKER_02: And it's not something necessarily that uh a medical doctor would would think of.
• 22:30
  SPEAKER_02: So it comes back, and I think it's a a very big responsibility of the coach to have the This knowledge and understand how to apply it practically.
• 22:42
  SPEAKER_02: And then, you know, I think that the athlete also has um uh somewhat of a responsibility as well to ensure that that they're using those strategies to get the best possible output to get the best possible performance.
• 22:56
  Coach Carlie: And and Corey, I will interject that that's also where the sports dietician comes in on the teams.
• 23:02
  SPEAKER_02: Yeah, definitely.
• 23:04
  Coach Carlie: We help with the the bridge between the physician and the coach and making sure that people are optimizing their what supplements to take and when optimizing their performance what in between food and so anyway, shameless plug, Corey.
• 23:17
  Coach Carlie: Go on.
• 23:18
  SPEAKER_02: We're gonna be able to do that.
• 23:20
  SPEAKER_02: I couldn't agree more.
• 23:22
  SPEAKER_00: Yeah.
• 23:23
  SPEAKER_00: Yeah, always gotta put the dietitian plug in there in every episode.
• 23:27
  SPEAKER_00: I love it.
• 23:28
  SPEAKER_00: Yeah.
• 23:30
  SPEAKER_00: So speaking of all this uh this uh timing and strategizing, I have heard and experienced um that sometimes the oral iron supplements can cause some like GI side effects.
• 23:45
  SPEAKER_00: So how do you suppose if you're having to take it in the morning, like say before practice or before your workout or training session, do you have any strategies or tips on how to mitigate those GI effects?
• 23:59
  SPEAKER_02: Yeah, it's very common.
• 24:01
  SPEAKER_02: Uh any I think I've seen research that shows anywhere between 40 to up to 60% of individuals have adverse uh effects from oral iron supplements.
• 24:13
  SPEAKER_02: And there's a few strategies that uh you can employ to to potentially help with that issue.
• 24:19
  SPEAKER_02: The I think the biggest one is to take iron.
• 24:24
  SPEAKER_02: So I would actually advise this as well, even if you didn't have GI upset, is to take the iron supplement uh once every second day and not once a day.
• 24:36
  SPEAKER_00: Okay, interesting.
• 24:39
  SPEAKER_02: So the body is horrible at absorbing iron, and when it does absorb iron, it is very quick to shut the door.
• 24:48
  SPEAKER_02: So when you take an iron dose, it paradoxically increases hepsidan as um uh a response and decreases iron absorption.
• 24:58
  SPEAKER_02: Now, if we were to take another dose the next day, and research has has demonstrated this, that you actu actually have less absorption due to the hepsidan response from the first dose.
• 25:10
  SPEAKER_02: So some research has even demonstrated that over a a four-week period, let's say, that you have a greater iron absorption from taking the dose once every second day.
• 25:23
  SPEAKER_00: Wow.
• 25:23
  SPEAKER_00: Like in total for the four weeks.
• 25:26
  SPEAKER_02: Yeah, correct.
• 25:27
  SPEAKER_02: So it yeah, almost is paradoxical because you're taking half the amount of iron, but you're can uh absorbing more.
• 25:38
  SPEAKER_00: Yeah, that's really good to know.
• 25:40
  Coach Carlie: And I assume, Corey, this is ferrousulfate more likely than like uh like a bisglycinate or something like that, because it seems like ferrosulfate is probably the most researched, I would guess.
• 25:52
  SPEAKER_02: Yes, ferrousulfate is the most research, and it was, I think it was the uh initial one as well.
• 26:00
  SPEAKER_02: So iron supplementing started, actually started in the 1600s, and that was that was introduced with iron filings in cold red wine.
• 26:14
  Coach Carlie: Which is not like a great concoction.
• 26:17
  SPEAKER_02: No, no, no.
• 26:19
  SPEAKER_02: Um, but hey, treatment had to start somewhere, someone had to had to try.
• 26:24
  SPEAKER_02: So that's where that's where it started, and it yeah, slowly moved to to I think ferrous sulfate was the first oral pill that was developed in the the 1800s, don't quote me there, but yes, ferrousulfate would be the most common, and you would get roughly 20% of that absorbed.
• 26:45
  SPEAKER_02: Similarly, ferrous uh bisglyfinate is roughly, depending on the research, you can see similar absorption rates.
• 26:53
  SPEAKER_02: Now, if you are someone that has significant GI upset from the oral tablet, then a lot of people um suggest taking ferrous bisglyfenate over the ferrous sulfate, or at least trying it.
• 27:07
  SPEAKER_02: So if it's something that you know you you're not tolerating well, then it would be worth trying to change something up to see if that is any better.
• 27:18
  SPEAKER_00: You mentioned that the oral supplements are all non-heme iron, is that correct?
• 27:23
  SPEAKER_02: Yes, that's correct.
• 27:24
  SPEAKER_00: Is there any way to isolate heme iron?
• 27:28
  SPEAKER_00: Just wondering.
• 27:30
  SPEAKER_02: I had I did see something on the market.
• 27:32
  SPEAKER_02: I think this was uh last year at some point.
• 27:35
  SPEAKER_02: I I wouldn't be able to tell you what specifically it is, but yeah, I think there are a few.
• 27:43
  SPEAKER_02: I'm not sure about the research behind them, but the main way to get heme iron is to be consuming your animal products in the diet.
• 27:51
  SPEAKER_02: Now that's not to say I would never say to if I was a coach, uh, if an individual, a female athlete is vegetarian for whatever reason they choose to be, which is completely fine, I would never say, okay, the strategy to improve your iron status is to start eating meat.
• 28:11
  SPEAKER_02: I think that comes back to the individualization of the uh the coach in terms of their screening.
• 28:18
  SPEAKER_02: I've had I've seen people go to doctors, and doctors have said, okay, you need to, you know, change this practice.
• 28:25
  SPEAKER_02: And yeah, I don't think that's that's very effective coaching.
• 28:29
  SPEAKER_00: Yeah, not necessarily the answer.
• 28:31
  SPEAKER_00: And if they're not going to do it, then it's not a good recommendation for them either.
• 28:36
  SPEAKER_02: Yeah, exactly.
• 28:38
  SPEAKER_00: So maybe you're somebody who struggles to who or chooses not to eat red meat for for whatever reason.
• 28:45
  SPEAKER_00: In addition to supplementation, I've also heard of some other ways to get in iron in your diet.
• 28:52
  SPEAKER_00: Like either cut like cooking with cast iron is supposedly supposed to like you know, your food's supposed to absorb some of that iron from the pan or something.
• 29:01
  SPEAKER_00: How how true is this and how much does it contribute?
• 29:06
  SPEAKER_02: This was this was actually a journal club for my lab a couple of months ago.
• 29:11
  SPEAKER_02: It was very interesting.
• 29:13
  SPEAKER_02: The the idea behind it's very plausible, right?
• 29:17
  SPEAKER_02: You know, uh to try and increase the iron that's coming into a food source.
• 29:24
  SPEAKER_02: And research shows that you can increase the iron in a source, for example, um tomato sauce, which is very acidic, you can increase it by 800% roughly.
• 29:37
  SPEAKER_02: Now, in saying that, you're actually not consuming almost any of it.
• 29:42
  SPEAKER_02: So it comes back, it's a non-heme form of iron, it's poorly absorbed, and research has demonstrated well one of the biggest randomized control trials on the the lucky ironfish, as it's called, is um it suggests that it doesn't improve ferritin or hemoglobin.
• 30:03
  SPEAKER_00: Man, okay, because I saw I didn't actually find out about the lucky ironfish until a few days ago.
• 30:09
  SPEAKER_00: I saw an ad for it and was really like excited about it.
• 30:13
  SPEAKER_00: I was like, this could be great.
• 30:14
  SPEAKER_00: Because it's it's for those of you that might not know about it, it's literally just it's an iron fish, like it looks like a paperweight kind of, and you're supposed to put it into if you're boiling water, if you're making soup, if you're making curry, just anything like liquid, if you put it into like a pan and boil and and like when you're cooking and then take it out afterwards, it's supposed to have like released some iron into the food or the or the water.
• 30:40
  SPEAKER_00: But man, I'm sad that that's not actually the quick answer to this.
• 30:45
  SPEAKER_02: Well, there is research.
• 30:47
  SPEAKER_02: I would would be, you know, not giving the whole picture if I was to say that that was just the only study.
• 30:55
  SPEAKER_02: There are studies, smaller studies that have demonstrated a weak improvement in hemoglobin and ferritin.
• 31:02
  SPEAKER_02: However, these were much smaller studies, non-randomized.
• 31:07
  SPEAKER_02: Um, so as a as a researcher, I always go looking for the the big randomized double blind control trial.
• 31:14
  SPEAKER_02: And the one about the lucky ironfish was in 2017, and yeah, that suggested no no gain, unfortunately.
• 31:21
  SPEAKER_00: Ah too bad.
• 31:24
  SPEAKER_00: So I guess we gotta go back to the basics, stick to the dietary sources, and then supplementation if needed, or infusions if needed.
• 31:33
  SPEAKER_02: Yeah, definitely.
• 31:35
  SPEAKER_02: I think it does always come back to to screening the athlete because it gives you the information you need to have strategies in place to ensure optimal performance.
• 31:46
  SPEAKER_02: And this is, you know, in the context of exercise performance, this is this is important.
• 31:52
  SPEAKER_02: However, you can even take a step back and see that it impacts quality of life of the individuals affected.
• 31:59
  SPEAKER_02: And, you know, it's not necessarily just something in the exercise world.
• 32:04
  SPEAKER_00: Definitely right about that.
• 32:06
  SPEAKER_00: Do you have in mind like how often you should be getting screened for iron status if you're somebody who's competing and training a lot?
• 32:15
  SPEAKER_02: Yeah, there's a lot of really cool research out there that's coming out suggesting different kinds of screening practices.
• 32:22
  SPEAKER_02: I recall a it's a paper by Mark Sims in 2019.
• 32:27
  SPEAKER_02: I think he suggested to screen at least twice a year for iron, and that could be changed depending on how susceptible you are to iron deficiency and whether you've had it or not previously.
• 32:44
  SPEAKER_02: So building a screening tool is very much the research I'm involved with at the moment, and we're trying very hard to figure out a way to predict iron deficiency without necessarily having to take blood out of the individual, because uh, if you take blood out of the individual, you take out iron and therefore more susceptible to iron deficiency.
• 33:05
  SPEAKER_00: So counterproductive there.
• 33:07
  SPEAKER_02: Yes.
• 33:08
  SPEAKER_02: You want to test for it, you need to lose some.
• 33:11
  SPEAKER_02: So we're um, yeah, we're trying very hard to develop screening tools that that don't necessarily need to involve a blood test.
• 33:19
  SPEAKER_00: Well, Corey, when you come up with your screening tool, you're gonna have to send it, you're gonna have to let me know, and I want to see it because one of the things for my project, the school project I was working on, was they wanted us to um kind of we we didn't need to find like a screening tool out there that already fit every single thing, but we needed to find something similar and adapt it.
• 33:41
  SPEAKER_00: And it was really, really difficult to find an iron screening tool for that that like adolescent age, like age would understand, and like it wouldn't be too long to fill out or whatever.
• 33:54
  SPEAKER_00: So I'm really interested in that too.
• 33:57
  SPEAKER_02: Yeah, it's um like you said, the the difficulty comes from so many different angles.
• 34:02
  SPEAKER_02: The non-specific symptoms, the lack of recognition, the underdiagnosed, undertreated, all of these things play important roles for any screening tool.
• 34:16
  SPEAKER_02: And iron deficiency, unfortunately, has all of them together.
• 34:21
  Coach Carlie: And I know we've been focusing more on females, but it happens in men too.
• 34:26
  Coach Carlie: And I've also seen it in peri and menopausal women as well.
• 34:30
  Coach Carlie: So it's sort of this carryover from perhaps a history of anemia now, you know, no more menstruation, but their iron is still tanking.
• 34:39
  Coach Carlie: So it's it's uh an important tool to have some sort of screening for people who want to be lifelong athletes.
• 34:47
  SPEAKER_02: Like definitely.
• 34:49
  SPEAKER_02: I think I think it should be for for anyone and everyone, as most recent prevalence rates have one one-third of the human population is iron deficient.
• 34:59
  Coach Carlie: Wow.
• 35:00
  Coach Carlie: That's a big chunk.
• 35:01
  Coach Carlie: That's that's massive.
• 35:03
  Coach Carlie: Yeah.
• 35:04
  Coach Carlie: Gracious.
• 35:05
  Coach Carlie: And then, you know, to to your point of how potentially detrimental all this pounding and running is for iron.
• 35:14
  Coach Carlie: And then oftentimes, like we had a gentleman in the lab today and he's training six days a week and you know, or running six days a week, more specifically.
• 35:23
  Coach Carlie: So I'm not telling people to not run, but sounds like keep track of your metrics in conjunction with what your training looks like so that you can stay on top of adequate iron stores.
• 35:36
  SPEAKER_02: Yeah, that's exactly right.
• 35:37
  SPEAKER_02: And I think it comes similar to so many other things, you know, like if you have an injury, then it's, you know, really important that you get all the information available around that injury and then come up with a plan moving forward as to rehab and then getting back on the track or whatever it is that you're training for.
• 35:57
  SPEAKER_02: I think nutrition is is not very much different to that.
• 36:01
  SPEAKER_02: And I think it's important to screen.
• 36:03
  SPEAKER_00: Or is there anything else you wanted to touch on, Corey, before we wrap up?
• 36:07
  SPEAKER_02: I did write one thing down about intravenous iron infusions.
• 36:11
  SPEAKER_02: I did a bit of research just trying to make sure that I could cover all the points, and I saw something interesting that I didn't know was a rule, but the the wada iron infusion ruling is an elite athlete that's bound by water law, any infusion greater than a hundred milliliters across 12 hours is it's actually banned at all times without exemption.
• 36:36
  SPEAKER_02: So I think it's important.
• 36:38
  SPEAKER_02: Yeah, yeah, it's banned.
• 36:40
  SPEAKER_02: I think it's really important that if you are in that elite athlete context to understand the the wider regulations around this.
• 36:49
  SPEAKER_02: Now you can get exemptions if you are anemic or you definitely need it, you know, as a as a solution.
• 36:57
  SPEAKER_02: However, if you engage with it and then don't, you know, go through those right channels, then yeah, there are potentially consequences.
• 37:06
  SPEAKER_00: Wow.
• 37:06
  SPEAKER_00: Okay.
• 37:07
  SPEAKER_00: Yeah.
• 37:07
  SPEAKER_00: So be careful out there if you're getting some iron IV infusions.
• 37:12
  SPEAKER_00: But yeah, very interesting.
• 37:15
  SPEAKER_00: This was awesome.
• 37:15
  Coach Carlie: Corey, you are so knowledgeable.
• 37:17
  Coach Carlie: I'm so thankful that Emily found you and we were able to interview.
• 37:22
  Coach Carlie: This was so awesome.
• 37:24
  SPEAKER_02: No, thank you so much for for having me on.
• 37:27
  SPEAKER_02: And as I said, I'm very passionate about this this field of work.
• 37:31
  SPEAKER_02: So any opportunity I can get to raise awareness, I'm I'm always gonna take it.
• 37:36
  Coach Carlie: Awesome.
• 37:36
  Coach Carlie: Well, when we get this all published and good to go, we'll send it your way and um and we're gonna, you know, send it to as many endurance athletes as we can and and uh whomever is listening.
• 37:47
  Coach Carlie: So this was great.
• 37:48
  Coach Carlie: And it's so it's so awesome to hear it from the horse's mouth.
• 37:51
  Coach Carlie: You know what I mean?
• 37:52
  Coach Carlie: So especially in the age of TikTok and Instagram, where's happening, right?
• 37:59
  SPEAKER_00: Yeah, but this is like your whole career, so we want to hear it from you.
• 38:03
  SPEAKER_00: Yes, yeah.
• 38:04
  SPEAKER_02: We've actually published, we've published a paper, or we took a bit of research to a conference that was looking actually at the information on TikTok regarding iron deficiency and iron status.
• 38:17
  SPEAKER_02: And it's yeah, it's quite alarming the amount of well, I I suppose it's not surprising, but it's it's alarming the amount of misinformation out there around this topic.
• 38:28
  SPEAKER_02: And yeah, I think that's also an important thing to to have as a consideration.
• 38:35
  Coach Carlie: Wow.
• 38:35
  Coach Carlie: That yeah, don't get your health advice from social media, I think is the the short answer to that, perhaps.
• 38:41
  Coach Carlie: Online, uh-huh.
• 38:43
  unknown: Yeah.
• 38:43
  Coach Carlie: Yeah.
• 38:44
  Coach Carlie: Yeah.
• 38:45
  Coach Carlie: Yeah.
• 38:46
  Coach Carlie: And uh, and just to confirm, this was not specific medical advice.
• 38:49
  Coach Carlie: Make sure you speak to your healthcare providers when it comes to um medical interventions.
• 38:54
  Coach Carlie: We are this is here for educational and perhaps even entertainment.
• 38:58
  Coach Carlie: So uh but this was awesome.
• 39:03
  Coach Carlie: Thank you so much, Corey and Emily.
• 39:04
  Coach Carlie: Great job.
• 39:06
  Coach Carlie: Thank you.
• 39:08
  Coach Carlie: It's so good.
• 39:09
  SPEAKER_02: Awesome.
• 39:10
  SPEAKER_02: Thanks again, guys.
• 39:11
  Coach Carlie: All right, yeah, thank you.