Wednesday, July 18, 2012

Ironing Out a Kink in My Armor - Ferritin Testing for Endurance Athletes

About a month ago when in Portland for a track meet I took it upon myself to get my ferritin levels checked, something I’ve been meaning to do for a while, but just hadn’t gotten around to.  Why, might you ask, did I think I needed to know what my ferritin levels were?  Well, there are a few reasons, but first and foremost, it was not because I thought I was sick or my diet was inadequate or I was feeling especially fatigued in my training and racing.  I mean, sure I would be tired after a hard long run or speed session, but who wouldn’t be and isn’t that sort of the point of a hard workout, to push yourself a little beyond your comfort zone before recovering and doing it all over again? 

No, I had my ferritin checked simply because I wanted to establish a baseline measure for ferritin and to know just how well my body was storing iron.  As an endurance runner, iron plays an important role in our performance and ability to move oxygen via the red blood cells to our fatigued and damaged muscles. 

Ferritin is a naturally occurring protein in the liver, spleen, bone marrow, muscles, and blood which stores and releases iron as needed.  As a result, ferritin levels serve as a kind of proxy measure for the amount of iron available and stored in one’s body.  The specifics of these processes and the different roles of ferritin/iron moving oxygen and muscle repair are more complex than this non-medical professional needs to attempt to understand or restate here.

Suffice it to say, if a runner has low amounts of iron in their body, they will likely not be able to perform as well as expected or desired.  In extreme cases of low iron levels one can be described as anemic or diagnosed as suffering from anemia.  Endurance athletes, especially runners, can be especially susceptible to lower iron levels, due to losses of iron that occur through sweating and through foot strike hemolysis in which red blood cells literally burst and are destroyed by the constant pounding of one’s foot strike.  In general, one is not destroying a significant portion on one’s run blood cells on their daily runs, but with higher mileage running, this can begin to add up and be a factor.  Menstruating women may also suffer from lower levels of iron resulting from monthly blood loss.  Obviously, it is important to maintain a reasonably high ferritin level or at least not have your ferritin levels decline to a level below the normal range.

Researching the topic online, one can find a variety of different values for the range of normal adult male ferritin levels with low ferritin described as anywhere from under 10 to under 24 nanograms per milliliter of blood.  Overall, most online sources (for what that is worth) list 20-24 as low end of normal.

The results of my ferritin test were rather startling, with my numbers coming back at 22.  Wow, I was admittedly surprised.  That is at the very low end of healthy and borderline anemic (although my hematocrit and hemoglobin numbers were not high, they were not nearly as close to the low end of the reference range as the ferritin was).  In my mind I have a pretty healthy and balanced diet for a runner with a pretty good amount of animal protein.  I thought I ate reasonable, but regular, portions of red meat, the richest and most readily absorbed source of dietary iron.  But in learning more about this issue, I became more aware that how you get your iron and with what other foods can enhance or interfere with the iron absorption process.  Iron absorption is improved with the availability of vitamin C; whereas, calcium inhibits absorption of iron.  These are not one to one ratios, but rather are guidelines to remember and incorporate into one’s eating habits to maximize iron absorption.  As a unapologetic meat eater, I haven’t had to change my diet significantly or worry about where I might get added iron from non-animal sources; however, I am trying to increase my iron consumption from plant based, as well as animal based, sources and to cook a little more in cast iron pans which is purported to also add iron to the diet, although I am somewhat skeptical that it can be very significant.

Now, a month later, I am taking iron supplements in the form of ferrous sulfate tablets three times a day (3x65mg) with a vitamin C tablet and avoiding calcium rich foods near the window of time in which I take the iron supplements.  I am also eating more lean red meat in my meals and paying attention to what I am eating with my iron rich foods and supplements.  For example, am I drinking milk (dairy or almond) or eating ice cream near the time I am taking the supplements?  Am I having cheese on a pastrami sandwich (yes I am), and do I need to really worry about every time I mix a calcium rich food with an iron rich food?  Of course I don’t.  Food is a pretty big aspect of my life and I refuse to have my diet completely dictated by something like iron absorption vigilance.  But I am admittedly more aware of these things than I was before.

After a month of taking the supplements and rethinking my iron intake have I noticed anything different?  I think I have.  I feel much stronger and less tired in my legs in my hard workouts especially in longer intervals and tempo runs and I feel like I am recovering from runs much quicker than before.  I’m actually kind of excited to get in the right race and really see what happens.  It is not like I feel like superman, but I do feel that little bit more fresh and peppy than before.

Now the question becomes, to what level do I need to or want my ferritin levels to rise to?  Of course, I want to get the number up to a “healthy” value or more closer to the average for healthy adult men.  However, working to improve my iron stores and function, brings up another topic, namely that of supplementing to enhance performance as opposed to supplementing to reach healthy or average levels.  In general, men’s ferritin levels are found to be between 20 and 380 ng/ml.  For me it seems to make sense to get my ferritin to at least 50, but why not aim for higher?  It is fairly widely known these days that many elite endurance athletes intentionally take iron supplements to bring their ferritin levels to around 100 ng/ml or above as a means to maximize the muscle repair and oxygen moving effects of iron in their bodies.

Should consuming supplemental iron in pill or liquid form when you do not have a shown deficiency be considered a form of performance enhancement?  Yeah, it probably should, but what does that really mean?  Isn’t that the point of a training program and everything that goes into it, performance enhancement?  Of course that is the tricky question in sports today, where do you draw the line for what is or is not acceptable for performance enhancement, and why?  Most arguments are either based on creating and maintaining a level playing field or around protecting the health and safety of athletes, especially young athletes.  But in all honesty, that seems like a bit of a farce to me, since the point of training hard to be the best involves intentional stresses and pushing your body to extremes and beyond what is considered normal to force it to adapt and get stronger.   One is intentionally trying to find an advantage over your competitors and taking some risks, pushing to the edges of, and sometimes beyond what is normal or safe.  Like most things in life, the line that has been drawn to divide what is acceptable and what is not is relatively arbitrary and is based as much on opinion, convention, and emotions as it is on facts, data, and logic.  Am I advocating for the use of drugs in athletics?  Of course not, but I am not afraid to be honest and talk openly about their place in the bigger picture of training and competition.

Anyway, since this is my blog and is selfishly about me, back to the situation at hand.  Do I need to aim for a ferritin value around 100 or higher?  Not necessarily, but we shall see how this all unfolds and progresses when I get a follow-up ferritin test at the end of two months of supplementation.  Another test might be how my race results look after my body has had a chance to benefit from the effects of increasing my iron levels regardless of how close to 100 ng/ml they reach.  Another test might be how long I am willing to subject my digestive system to the effects of iron supplements, because there is most definitely a change in the “output”, and it ain’t always pretty.