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Iron deficiency anaemia

Last month, I wrote about noticing the impact of my period on my energy levels, fatigue, and ability to push myself in training. This sparked some interesting and useful conversations; thank you to everyone who got in touch to share their own experiences and offer advice and insight.


It also made me think that perhaps the time was right to discuss iron deficiency anaemia, a topic with which I have some personal history. I’m going to attempt to weave together my own story with a discussion of the symptoms, causes and treatments of the condition, and explain why it’s particularly relevant to female athletes. Please bear in mind that I have no medical training, or qualifications that enable me to give advice on the topic – if you are concerned about your own health, please go and see your doctor. I’ve included below the sources for all the information I mention, so that you can check it out for yourself, and I’ve made sure that I’m only including sources I personally trust.


Firstly, what is iron deficiency anaemia? There are two different, linked conditions here. Iron deficiency is simply a lack of iron stored in your body, which doesn’t necessarily in and of itself cause any issues with your exercise performance. Anaemia can be a consequence of iron deficiency (although there are other causes of anaemia too) and is when the levels of haemoglobin in your blood are too low. Haemoglobin is found in your red blood cells and is what enables your body to transport oxygen to your muscles. You need that oxygen for exercise, so it follows that if you can’t get enough of it to where it needs to be, your exercise performance is going to be impaired. [1]


I suffered from both chronic and eventually acute anaemia in the autumn and winter of 2015 and 2016. When I look back, I can see that I was a walking textbook, with all of the common symptoms plus a healthy (not so healthy!) selection of less common ones [2]. These symptoms developed slowly over time, slowly enough that I didn’t realise something was really wrong until it was quite advanced. I experienced persistent tiredness and shortness of breath (I became breathless climbing the stairs, and in the later stages I would have to spend twenty minutes each morning lying in bed before I could get up without feeling faint). I also became very pale, and my resting heart rate rose to over 100 beats per minute. To this day, I still have a much higher resting heart rate than you’d expect from someone who exercises as much as I do. You can easily see how this combination of symptoms would lead to difficulty running; at its very worst, I struggled to complete a 40-minute parkrun.


As things progressed, I developed some more unusual symptoms: mouth ulcers, a sensitivity to spicy food, restless legs, and pica, a condition which makes you want to eat non-food substances (in my case, ice). There are a few more symptoms that I didn’t suffer from: headaches, tinnitus, feeling itchy, having a sore tongue, hair loss. Things finally came to a head when I had a routine blood test; my doctor phoned me on a Friday afternoon as I was leaving work and instructed me to go straight to A&E, without passing Go or collecting £200. I was admitted to hospital and had four pints of blood transfused over the weekend. The effect was instant and transformative – apparently I literally looked like a different person with the colour returned to my face. At the start of the following week, I went out and jogged a 25-minute 5k without any appreciable effort. It took some time for friends to stop joking that my performances were doping-enhanced!


So, my first recommendation is to pay attention to your body, particularly if you have a few of these symptoms together. Request a blood test from your doctor. There are quite a few different tests performed within a full blood count, but two key ones are haemoglobin [7] (that’s the molecule which transports oxygen) and ferritin [6] (a measure of stored iron in your body). Low levels of either or both of these could represent a problem. Bear in mind that it is generally accepted that people who do large amounts of exercise need more iron than people who don’t [3] – so even if your test results are technically within the ‘normal’ range, they could still represent a low value for you personally.


Why does it happen? There are a range of reasons thought to contribute to the higher incidence of iron deficiency anaemia in athletes, and particularly in female athletes. An obvious one for the latter group is menstruation – if you are regularly losing blood from your body (and especially if you experience higher than average blood loss during your period), your body has to work harder to replace those lost red blood cells. There are some other possibilities too – it is thought that microscopic internal bleeding in the intestines can contribute, particularly in distance runners, along with broken blood vessels on the soles of the feet, caused by repetitive impact. This latter phenomenon is called ‘foot strike haemolysis’, although I found conflicting evidence on this one – some studies [4] claim to have proven definitively that it is a major contributor to haemoglobin loss, while others [5] say they have found no or negligible contribution. Either way, it does seem to be true that for whatever reason athletes, particularly female athletes, are more likely to suffer from iron deficiency anaemia than the general population.


What can you do about it, then? It’s probably a bad idea to let anaemia progress to the point where you need a blood transfusion. I should also mention, to avoid unduly alarming anyone, that there were some extra, complicating factors in my situation – particularly that I use a regular medication that is known to inhibit iron absorption from food. So hopefully it’s unlikely that most people would find themselves in a similar situation, especially if you pay even a little attention to your diet. Diet and supplements are the main ways to treat iron deficiency anaemia. The NHS [2] recommend the following as good sources of iron: dark green, leafy vegetables (such as kale), fortified cereals and bread (check packets in the supermarket – you may be surprised at how many brands fortify their products), meat, and pulses (beans, lentils). It’s worth being aware that foods contain two different types of iron – haem iron and non-haem iron [7]. The former is found in animal tissue, and the latter in plants, and we absorb haem iron much more easily. If you’re veggie or vegan, you may have to work harder to eat enough to absorb the amount you need. You might also want to consider supplements – I use supplementary iron tablets because I know that my medication leaves me vulnerable to not absorbing enough, even though I do eat (quite a lot of!) meat. I get mine on prescription from my GP, but there are various over-the-counter options available too. Finally, consider what you are eating and drinking alongside your iron intake, particularly if you’re taking it in tablet form. Vitamin C will boost your absorption, so taking supplements with orange juice is a great idea. Conversely, caffeine inhibits your uptake, so keep iron-containing food or supplements away from tea and coffee.


I hope this has offered both a personal perspective and some useful information on iron deficiency anaemia. All my sources are below, and I’d be keen to hear from anyone with a professional knowledge of this topic, particularly if I’ve made any errors or misunderstandings.


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