Login required to started new threads

Login required to post replies

Low ferritin - fatigue.
Quote | Reply
M49, whilst not vegetarian, my partner of 30years is so at home then rarely eat meat, when out I often choose fish - so for purposes of this call me a vegetarian. I've done some food tracking on MyFitnessPal and that suggests I get about 10% of my RDA of iron from my average week.

Was suffering with uncharacteristic fatigue on the days following a hard workout in period up to xmas. Admittedly working long hours, stressful time in the mix too, but was really made clear that each week my Wednesday 14km-16km run would be fine, then Saturday's long bike also good, but Sunday's longer run would be awful from the start, and I'd be absolutely 'spent' walking down the stairs in a morning Thursday Sunday/Monday. Also noticed lots of bruises that lasted for ages, some that appeared without me even knowing I'd bumped myself. A few years ago on physio advice I'd taken iron tablets for a while to address something similar and that was effective. So started taking them again between xmas and new year.

Did start feeling better after about a week, still don't think I'm 100%. Anyway had bloods done, noting this is a month after starting taking iron tablet supplements (I couldn't get in to get the bloods done pre for baseline). I've also had same tests done 18 months ago. Results below. My Dr Googling says that the results show that the iron supplements are ''working' to bring the iron back to 'normal' but the low ferratin is very much the lag indicator to show it was deficient. So far I've tolerated the iron tablets OK (720mg / day poly maltose equiv 200mg elemental iron) but still not totally without side effects.

So results.
Test Units 2022 post supplement Current
Iron umol/L 21 15
Ferritin ug/l 100 77
Transferrin g/l 2.62 2.58
Iron Sat % 35 25

Haemoglobin g/l 151 149
HCT L/L 0.45 0.45
MCV fL 91 91
MCH pg 30 30
WBC x10E9/L 8.4 7.9
Neut seg x10E9/L 5.5 5.1
Lymphocyte x10E9/L 2.0 2.1
Moncyte x10E9/L 0.7 0.6
Eosinophil x10E9/L 0.1 0.2
Basophil x10E9/L 0.1 0.1
Platelet Count x10E9/L 268 260

So questions to the pools panel.
1) I do eat green stuff. Spinach, kale, regularly as part of daily meals, eg salads. But I don't go out of my way to neck green smoothies every day. I'm not keen to get iron injections - whilst I may be able to get a TUE and indeed aren't currently in the running for placings I have a code that means I would very much prefer to manage this via diet or WADA 'green list' treatments. Has anyone else managed to make the changes to get from diet? As I say, based on my last 3 weeks then I'm not needing a 'bit more' iron, I'm needing a massive increase (or my specific foods aren't recording iron in myfitnesspal).
2) For the blood experts/medical geniuses/House-Good Doctor superfans - my itnerpretation of this correct, low iron, now being treated, but showing legacy of low Ferritin. everythign else looks good, so just treat the iron issue.
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
your hemoglobin and hematocrit are still very good which is great news . you havent started to kill off your red blood cells yet.

my advice - keep having iron pills 4-6 times per week for a few months and retest. also check if your b12 is a bit low - otherwise have the b12 pills or injections 2-3 x per month for a few months. b vitaminds are really important for fatigue and energy.

there are people who claim they can get their iron up with spirulina and kale shakes and all of that but i dont know if that is true. a guy called ash beech did a lot of intreesting YT videos on this a few years ago. a very good cyclist and a balanced YTer

ive not managed to keep my iron up on diet alone. iron and b12 deficiency affects meat and non meat eating people so if you are open to taking the supplement that should do the trick.
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
MD here (and one who manages patients with iron related issues daily).
What makes you think you have an issue with iron based on your blood results??
Quote Reply
Re: Low ferritin - fatigue. [Amnesia] [ In reply to ]
Quote | Reply
So this is after a month of 200mg a day iron tablets. The low(ish) ferritin which I (lay person, got my MD from Google) understand takes longer to come up than the iron itself. Symptoms matched low iron. And I know it would have helped to grab a test before the tablets, but didn't happen.

And as perhaps it's the full effectiveness of the Placebo I have been rigorously taking, but following taking iron tablets then things have improved each time. Also, and whilst I've not been able to give blood for last 15 years, then previously when I did give and they did that little drop test I was always borderline. I appreciate this last part could well be fortune teller logic.
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Duncan74 wrote:
So this is after a month of 200mg a day iron tablets. The low(ish) ferritin which I (lay person, got my MD from Google) understand takes longer to come up than the iron itself. Symptoms matched low iron. And I know it would have helped to grab a test before the tablets, but didn't happen.

And as perhaps it's the full effectiveness of the Placebo I have been rigorously taking, but following taking iron tablets then things have improved each time. Also, and whilst I've not been able to give blood for last 15 years, then previously when I did give and they did that little drop test I was always borderline. I appreciate this last part could well be fortune teller logic.

I guess that’s at the heart of my question.
Can you supply the reference ranges for your iron tests (I am based in Australia and different labs use different ranges).
And in conjunction with that, what’s making you therefore “think” that your iron is on the lowish side…(what google information is making you think that it’s lowish).
I just want to make sure that I understand things completely from your side before offering some insights (ie these questions are not intended to be criticisms etc, just wanting to ensure I understand where you are coming from etc).
Quote Reply
Re: Low ferritin - fatigue. [Amnesia] [ In reply to ]
Quote | Reply
NZ here.

It's not the iron that's low, it's the Ferritin. On the test there was a comment that under 100, whilst in 'range' is low so can't rule out iron deficiency.

Iron range 10-30
Ferritin 20-450 "Note ferritin in the lower range of normal (30-100 ug/L) may be unreliable in ruling out iron deficiency in the setting of inflammation, as ferritin is an acute phase reactant."
Transferrin 2-3.6
Iron Sat 20-50
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Duncan74 wrote:
NZ here.

It's not the iron that's low, it's the Ferritin. On the test there was a comment that under 100, whilst in 'range' is low so can't rule out iron deficiency.

Iron range 10-30
Ferritin 20-450 "Note ferritin in the lower range of normal (30-100 ug/L) may be unreliable in ruling out iron deficiency in the setting of inflammation, as ferritin is an acute phase reactant."
Transferrin 2-3.6
Iron Sat 20-50

Great stuff, that all makes sense.
It is a little hard to know where to start, but I will try and run through a few things with you in a logical (in my brain) sense.
This is part of my day to day role as a specialist in the hospital I work in, although dealing with a slightly different patient population (all female...!). I imagine most of what I say will be stuff you know about already, I have written some book chapters and review articles on this but from a slightly different angle to that of a male endurance athlete.
So iron is fundamental to the production of haemoglobin in your red blood cells and is important in the transport of oxygen from your lungs to your tissues.
Traditionally, the effects of iron deficiency are seen with the development of anaemia and across most of medicine this is by far the most common understanding of the consequences of iron deficiency. You are likely aware of the symptoms associated with being anaemic.
In more recent times, the syndrome of "non anaemic iron deficiency" is become more well recognised. That is, a greater recognition that iron deficiency on its own can lead to a variety of symptoms such as fatigue etc, even with normal haemoglobin levels like your own.
In terms of ferritin levels, your interpretation is pretty much spot on. Basically, a ferritin of <100 is suggestive of possible iron deficiency and <30 is diagnostic of iron deficiency.
The difficulty is, this syndrome of non anaemic iron deficiency becomes more likely the lower your ferritin values are. So the closer you are to say, 100, the less likely the symptoms you have are secondary to iron deficiency and the more likely they are secondary to other things (such as getting older!), whereas the closer your ferritin is to being super low (I see women in nearly every clinic I do with ferritins in the single digits) the more likely your symptoms are secondary to a low iron.

With your results, your iron levels are really nothing particularly unusual or stunning. On the balance of probabilities it would be more likely that your symptoms are secondary to other things rather than iron deficiency, although this may play a role. There are obviously lots of things that can start to impact your training and recovery as you get older and certainly, the forum is littered with posts of people having unexpected cardiac issues and other things which have presented with relatively mild initial symptoms such as prolonged recovery after sessions and not being able to quite hit the same outputs as they previously have done. It is incredibly difficult to run through all the potentials on here and really something you would want to run through with your GP.

Happy to chat more.
Usual disclaimers....this is the internet and hence as MDs we have to be incredibly cautious about giving medical advice etc in an online environment.....
Quote Reply
Re: Low ferritin - fatigue. [Amnesia] [ In reply to ]
Quote | Reply
Nice informative post doc.

For myself I keep an eye out for when hormones get too low and b12. Sleep and avoiding calorie deficits are useful in this.

Slow days and week can help with hormones. It’s unscientific but the woody test is useful. Obviously when hormones are peaked in teenage years remember what that was like waking up and compare with now

Hormone and testosterone tests can help with self knowledge of that. Does play with your mind a bit , if your hormones drop and you don’t feel good about yourself.

Obviously fatigue is contributed to more than just iron - for the OPs info in case they haven’t considered that

I’ve had lots of chats with GP and a sports dietitian on this plus own research
Quote Reply
Re: Low ferritin - fatigue. [Amnesia] [ In reply to ]
Quote | Reply
As always, really appreciate your post, even if it hasn't headed in the direction I thought we'd go when I posted. My GP has a slightly different philosophy to me on medication. He's of the prescribe first ask questions later. He was pushing iron injections, and also bizarrely testosterone (not had any tests to show that dropping, this was more a general age and if you do sports happy to prescribe that - as I say, we have very very different philosophies).

I didn't mention that in 2020 iron was at 11, ferritin 62 and Iron Sat 19%. 2016 Ferritin 59 (for some reason no iron bloods).

So this is why from past discussions with an earlier GP (she was awesome, a national rep level triathlete herself) it was something that seemed a likely cause.

Interesting what you say about your patients, and the challenge I'm having in finding an appropriate dietician. Honestly, my physio is trying to find one for me, but she's having the same issues - they are all focused on the diet issues pertaining to young females, not old men ;-)

And yes, I am aware that there are other reasons, including just old age (I admit this is scaring me and I'm in denial of that as a cause at this stage). Partly as it came on fairly quickly late last year, almost overnight from 'fine' to 'dip' where I'd expect age related decline to be more gradual.

But also the improvement from the iron tablets which as I say could be placebo effect, was positive. But in terms of ruling out iron prior to doing more tests then I thought it would be an easy start.

In terms of other things it could be, I'm confident that there's nothing major going on. It's getting better, not worse. I've still an FTP of 300w, doing 4+ hour group rides and if not quite winning the hill climbs then breaking the pack from the front and then finishing 10-15s behind the last two that came with me as they do a final sprint (was never my forte, I'm 20kg heavier than them!). Blood pressure and HR fine.
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
My go-to guy for all things cycling science related (Dylan Johnson) says low iron can cause fatigue, so there's that.
Quote Reply
Re: Low ferritin - fatigue. [Mudge] [ In reply to ]
Quote | Reply
I believe Dylan is vegan so he probably knows a thing or two about low iron levels.
Quote Reply
Re: Low ferritin - fatigue. [Mudge] [ In reply to ]
Quote | Reply
Mudge wrote:
My go-to guy for all things cycling science related (Dylan Johnson) says low iron can cause fatigue, so there's that.

Oh it sure can... found out after my first pro race (which was a disaster) that my ferritin had dropped to 4. Dangerously low for living let alone racing at a high level.

The fatigue and brain fog were crazy. It was like I was a different person.

Iron supplements, more of a focus on my diet (fish, spinach, Kix cereal believe it or not, etc) and I was back at full strength within a few months, but it was a tough time.

77 actually felt like full strength to me, compared to OP.. but it's all relative. I may be higher now and I may have been low for a long time.

But yeah man that fatigue... it's crazy.

Too old to go pro but doing it anyway
http://instagram.com/tgarvey4
Quote Reply
Re: Low ferritin - fatigue. [MrRabbit] [ In reply to ]
Quote | Reply
Thanks for that. I'm feeling a lot better now than I was a month ago, so what I'm trying to work out is how to keep the levels at this (or a bit higher) through diet not supplements with the drawbacks/side effects of those. Seems like first change is to increase the fish from typically once a week to three times. Cereal is an interesting one, I'd not thought of that. Whilst I tend to start the day with some toast and honey (5am) then I do then have a 9:30 snack of muesli and fruit. So perhaps I can switch that up to get some iron in.

I am really appreciating all the discussion, especially the rich seam of professional knowledge and shared experiences. Thank you.
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Watching on this one with interest.

(I ended up in a a bit of a hole in mid 2019... I'll take your ferretin reading of 11 and raise you... to 7 ! ). Heamaglobin levels lower than normal too. I've sort of yoyo'd since... 3 months taking ferrous fumarate it's all back up to n ormal.... stop....drops...and repeat.
Quote Reply
Re: Low ferritin - fatigue. [BobAjobb] [ In reply to ]
Quote | Reply
Chronic anemic here (get tested 2x per year), since college running days. My body does not do a good job at actually metabolizing iron pills so I switched to liquid iron with a vit c tablet and it seems to be helping. https://www.amazon.com/...ref_=chk_typ_imgToDp
Quote Reply
Re: Low ferritin - fatigue. [Jimi Sendrix] [ In reply to ]
Quote | Reply
How do you go with gut health with the liquid iron?

I'm slightly worried that the last thing I've seen is that tea and (red) wine inhibit iron absorption then I am at the point of being asked to cut out the only two things that make life bearable to me, and me bearable to others....
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Take a look at the absorption time windows. Say someone has a big vitamin c rich breakfast and an iron pill, then they have a few cups of tea or a wine later in the day. I don’t think the absorption is as hindered as much as if it was having the supplement then washing it with a red wine

I’m sure you can find some stuff on Google about that

But really as long as the periodic blood tests trend upwards you’re all g
Quote Reply
Re: Low ferritin - fatigue. [waverider101] [ In reply to ]
Quote | Reply
All good, even I don't drink wine with breakfast.

I find that the taste of the morning Guiness masks the subtlety of the grape....
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Haha. Whatever floats your boat. Personally a few spoonfuls of Kahlua in my morning brew was a favourite way to get going in my early 20s
Quote Reply
Re: Low ferritin - fatigue. [waverider101] [ In reply to ]
Quote | Reply
waverider101 wrote:
Haha. Whatever floats your boat. Personally a few spoonfuls of Kahlua in my morning brew was a favourite way to get going in my early 20s

Small world. That was the 'flat drink' at uni. We'd have a bottle each, 4 pints of milk. And essentially have coffee milkshakes for all day benders always staying at the right level of merry with a fully lined stomach. In hindesight the mid 90s as a student in London where limited budget meaning a choice between food and beer and resulted in the option to just drink Guiness as it ticked both boxes probably has a lot to answer for now...
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Duncan74 wrote:
How do you go with gut health with the liquid iron?

I'm slightly worried that the last thing I've seen is that tea and (red) wine inhibit iron absorption then I am at the point of being asked to cut out the only two things that make life bearable to me, and me bearable to others....

Big coffee drinker here, also hurts absorption. But I usually have to get up to use the bathroom at some point in the night, I just take iron and vitamin C then (4-5 AM?) and by the time I want coffee I'm good to go. You only need a couple hours buffer for the supplements.

Sure it hurts how much of the iron I get from my Kix, but I have to live. And with a full time job, a toddler, my 40th birthday approaching, and a pro race schedule to work out... I'm not dropping the coffee.

Too old to go pro but doing it anyway
http://instagram.com/tgarvey4
Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
I am a GP. I agree with Amnesia it seems unlikely you are iron deficient. Iron from green stuff is poorly absorbed so it is hard to get all the iron you need on a vegetarian diet I think. An acid stomach environment is important to absorb iron. The stomach is usually quite acid unless you are on a proton pump inhibitor. It is unusual to see males that are iron deficient though unless they are losing blood from their gut or have poor absorption. For instance I have a pt who only has one third of his stomach and needs to get Iron intravenously periodically.

Iron injections are nasty things from the past. I saw a few pts twenty years or more ago that got them. They leave you with these big black blotches under the skin at times. If somebody poorly absorbs oral iron we give iron intravenously. Iron sucrose is much safer than the older forms.

They constantly try to escape from the darkness outside and within
Dreaming of systems so perfect that no one will need to be good T.S. Eliot

Quote Reply
Re: Low ferritin - fatigue. [Duncan74] [ In reply to ]
Quote | Reply
Duncan74 wrote:
I am really appreciating all the discussion, especially the rich seam of professional knowledge and shared experiences. Thank you.
I'll add to the richness, but can't promise professionalism. Certainly a related experience.

I just wanted to call out that taking ferrous sulfate works, and sometimes more is the answer.(the most common and cheap OTC pill iron form in the USA). I just want to call that out because I often hear folks going for 'better absorbed' this or that. My wife and I have found much better results just taking more of the cheap stuff. You take enough of the ferrous sulfate and your ferritin will increase. Promise. (barring a serious pathology)

How do I know? During peak tri training my wife needed to take 6-8 ferrous sulfate pills per day to get her iron to be where it needed to be. No shots needed. We tried all the "better absorbing" stuff. All the timing and avoiding with such and such. "More" was the only effective answer.

Warning Number 1: eat your veggies or you'll be constipated.

Warning Number 2: if you get injured and you have to slash training volume by 90% (down to 10%, for clarity), you gotta cut your iron supplementation. :)

We/she forgot to do that, and after 6 months she had severe hyperferritinemia to the extent that the hematologist in the best cancer center near us would not believe that a person could have caused this in themselves. Everyone suspected hemochromatosis. It took 8 weeks of testing to prove to them it was caused by supplementation. Leave it to a phd in sport phys married to a performance-hungry pro triathlete with an RD/CSSD to systematically overdose on cheap-o iron and freak out an entire hematology clinic. It took about a year but she's back down in normal range. No iron supps needed for a few more months ;)

The lesson we learned (besides reducing iron intake when training gets slashed) was that indeed you can take more of the cheap stuff, with or without your vit C or inhibited by wine and coffee and any other thing, and it will indeed raise your ferritin. Just gotta take enough of it.

If I were in a position of low ferritin, I'd just dose up over the counter cheap iron pills and test my ferritin every 3-4 weeks until I got it where stable where I wanted it. (assuming the higher ferritin was indeed associated with a reduction in fatigue.) Definitely also heed all real MD's advice ahead of mine here.

As I've mentioned on a few posts today: I'm not an MD. Check with your personal physician before taking internet forum advice. :)

Dr. Alex Harrison | Founder & CEO | Sport Physiology & Performance PhD
-------------------------------------------------------------------------------------------------------------------------------------------------
📱 Check out our app → Saturday: Pro Fuel & Hydration, a performance nutrition coach in your pocket.
Join us on YouTube → Saturday Morning | Ride & Run Faster and our growing Saturday User Hub
Quote Reply
Re: Low ferritin - fatigue. [DrAlexHarrison] [ In reply to ]
Quote | Reply
DrAlexHarrison wrote:
Duncan74 wrote:
I am really appreciating all the discussion, especially the rich seam of professional knowledge and shared experiences. Thank you.
I'll add to the richness, but can't promise professionalism. Certainly a related experience.

I just wanted to call out that taking ferrous sulfate works, and sometimes more is the answer.(the most common and cheap OTC pill iron form in the USA). I just want to call that out because I often hear folks going for 'better absorbed' this or that. My wife and I have found much better results just taking more of the cheap stuff. You take enough of the ferrous sulfate and your ferritin will increase. Promise. (barring a serious pathology)

How do I know? During peak tri training my wife needed to take 6-8 ferrous sulfate pills per day to get her iron to be where it needed to be. No shots needed. We tried all the "better absorbing" stuff. All the timing and avoiding with such and such. "More" was the only effective answer.

Warning Number 1: eat your veggies or you'll be constipated.

Warning Number 2: if you get injured and you have to slash training volume by 90% (down to 10%, for clarity), you gotta cut your iron supplementation. :)

We/she forgot to do that, and after 6 months she had severe hyperferritinemia to the extent that the hematologist in the best cancer center near us would not believe that a person could have caused this in themselves. Everyone suspected hemochromatosis. It took 8 weeks of testing to prove to them it was caused by supplementation. Leave it to a phd in sport phys married to a performance-hungry pro triathlete with an RD/CSSD to systematically overdose on cheap-o iron and freak out an entire hematology clinic. It took about a year but she's back down in normal range. No iron supps needed for a few more months ;)

The lesson we learned (besides reducing iron intake when training gets slashed) was that indeed you can take more of the cheap stuff, with or without your vit C or inhibited by wine and coffee and any other thing, and it will indeed raise your ferritin. Just gotta take enough of it.

If I were in a position of low ferritin, I'd just dose up over the counter cheap iron pills and test my ferritin every 3-4 weeks until I got it where stable where I wanted it. (assuming the higher ferritin was indeed associated with a reduction in fatigue.) Definitely also heed all real MD's advice ahead of mine here.

As I've mentioned on a few posts today: I'm not an MD. Check with your personal physician before taking internet forum advice. :)

Thanks Alex,
Just wanted to provide a caveat to your post.
Many patients (I say patients as in those I care for) cannot tolerate oral iron to anywhere neat the extent you are describing. It can have some pretty nasty GI side effects and is often one the key reasons we switch to IV iron.
A question re your wife-do you know why she was losing so much iron in training? There is reasonable evidence (and this is less well commonly known outside of sports medicine etc etc) that you lose a lot of iron in sweat and this in itself can often cause iron deficiency in those who may already be at risk of it.
Quote Reply
Re: Low ferritin - fatigue. [Amnesia] [ In reply to ]
Quote | Reply
She trained a lot, and loses a lot with her cycle. We did tend to travel a fair bit for warm climates so she could train in the sun. *shrug*

She initially reported the nasty GI side effects but nothing that couldn't be fixed with miralax and truckloads of leafy greens.

Dr. Alex Harrison | Founder & CEO | Sport Physiology & Performance PhD
-------------------------------------------------------------------------------------------------------------------------------------------------
📱 Check out our app → Saturday: Pro Fuel & Hydration, a performance nutrition coach in your pocket.
Join us on YouTube → Saturday Morning | Ride & Run Faster and our growing Saturday User Hub
Quote Reply