This is a long-overdue post, and one I’ve been meaning to write for months now. It’s also content-loaded, so grab your favourite beverage and a snack, and let’s have a chat.

Over the past year I’ve received several emails, blog comments, and in-person questions about how I found out I had anemia and how I’ve dealt with it. There have been a number of posts where I’ve talked about the various supplements I tried and the impact that all of this had on my training throughout 2013, but after having had a really successful 2014 in terms of getting my ferritin levels up (more about what this is in a second), I figured it would be a good time to put everything in one place.

Photo credit: abhijith3747 / Fotolia

Photo credit: abhijith3747 / Fotolia

How it all began

Let’s rewind to May 2013. I’d just run the Goodlife Toronto Half Marathon, and while it wasn’t a PR, I still had an ok race. I hadn’t done much outdoor training prior to that race but had been logging plenty of miles on the treadmill through the winter and early spring. My hill-hating self really didn’t like the enormous slope around mile 3 of the course, and I remember it feeling really hard. It took me longer than expected to bring my heart rate back down in the miles that followed, but eventually I got back into my groove and carried on for the rest of the (reasonably flat) course.

my bib for the half marathon

I got home after the race, showered and ate, but couldn’t stay awake later in the afternoon. I napped, woke up for dinner, then went straight back to bed.

In the days that followed, I eased back on my workouts as usual post-race in order to recover properly. Normally after a half marathon I have the energy to get right back into training in the days that follow and it’s more an issue of forcing myself to hold back that I deal with, but this time, I couldn’t shake the tired feeling. Even an easy elliptical workout felt like a challenging sweat session.

About a week later, I went on a mini-holiday to Montreal. My plan was to run a bit outside while I was there, but it rained for almost the entire trip and I didn’t feel like it. Feeling like I should at least get some sort of physical activity, I did a couple of TurboFire workouts. These don’t normally make me sweat very much but I found my heart rate jumping up way too early every time I tried. I napped most afternoons and slept at least 8-9 hours each night.

After 2 weeks of being back home in Ontario, my running fitness still wasn’t where I expected it to be. My energy during the day at work was ok, but every time I tried to do any sort of cardio, it felt as though my legs were suffocating within about 5 minutes. It was like enough air just couldn’t get into my body with each breath and before I knew it, I was dripping with sweat. For someone who has been starting the majority of her days with physical activity for the last 9ish years, this was frustrating and I knew it wasn’t normal.

Doctor says…

I made an appointment with my (at the time) family doctor to describe what was going on, and to request bloodwork. I mentioned that I suspected my iron might be low, because like every patient does, I’d already done plenty of self diagnosing with the help of Dr. Google.

I brought up the possibility of footstrike anemia, also known as footstrike hemolysis or hemolytic anemia. In simple terms, one of the causes of this type of anemia is the repeated crushing of red blood cells with every strike of the foot. (Seriously, it’s a thing and here’s a study about it.) As you may have guessed, this is a common diagnosis for runners to receive since a runner’s feet are constantly pounding pavement (or treadmill belts). My doctor said she’d never heard of it, Googled it, and told me that I should just stop running. Um…. no.

Annyways, she gave me the form I needed to get the blood taken. About a week after having it done, I called to follow up because I hadn’t heard anything.

The nurse told me on the phone that the results showed an iron deficiency and that my doctor recommended taking an iron supplement. No mention of what kind, how low my iron levels were, how low my iron was, or what dose. I asked these questions, and the response was “just a standard iron supplement from a pharmacy should do the job.” I asked to get a copy of my results and was told yes, as long as I went into the clinic and paid $1 per page to have them printed. (Seriously?! But I did it.)

lab test screenshot

Iron deficiencies come in many forms, and there are a number of things that need to be considered – red blood cell count and size, hematocrit, hemoglobin, and ferritin. In my case, things were low across the board but what needed the most attention was ferritin. Mine was rock-bottom. Let me quickly explain what this measurement means.

What’s ferritin?

Ferritin is a protein that allows the cells of our bodies to absorb iron. Most of our ferritin stores are in the liver, spleen, muscles and bone marrow, and this number on a blood test indicates how much iron is stored in the body. The normal range for women is broad – 11 to 307 nanograms per milliliter according to the Mayo Clinic – but do you want to take a guess at what mine was? 4. Pretty much non existent. My naturopath at the time took a look at the results and confirmed that I was about as anemic as it gets.

And so the supplement testing began…

Contestant #1: Salus Floradix by Flora Health

Details: Each 10mL dose (to be taken 2x daily) contains 10mg elemental iron in the form of ferrous gluconate, as well as vitamins B1, B2, B6, B12. The liquid needs to be stored in the fridge, but this supplement also comes in tablets that do not. Full specs can be found here.

floradix iron

Floradix was recommended to me by a few naturopathic doctors, holistic nutritionist friends, and female endurance athletes. It’s known for being easy on the gut, vegetarian-friendly, and easily absorbed. By easy on the gut, I’m referring to two key things: No stomach aches and no ‘backed up pipes’ – a very common side effect of iron supplements! This one didn’t cause me any problems, and I did feel better after a few days. However, I think it’s just because my iron was SO low that anything would have helped. After two months, I was back to my tired self and my blood tests showed no improvement.

Contestant #2: Genestra Liquid Iron

Details: Each teaspoon (5mL) contains 15mg iron in the form of ferric pyrophosphate. The recommended dose for adults is 1 teaspoon 2x daily (a total of 30mg iron), or as recommended by a healthcare practitioner. Mine told me to take 2 tablespoons, or 90mg daily. Full specs can be found here.

genestra liquid iron

Another liquid iron was up next because I’d been told that these are typically easier on the gut. By this time – around fall of 2013 – I was struggling with some bad digestion issuesso this was a top priority. Genestra Liquid Iron is vegan friendly, has a decent taste (I liked it better than Floradix, which tasted like funky grape juice) and didn’t cause me any problems.

This supplement got me through for most of the fall and winter, and while I started to feel improvements in my fitness on a consistent basis, I still wasn’t fully back to normal and my ferritin number had barely moved. Back to my family doctor I went, begging for a referral to a specialist, which she gave me. (I also got a new family doctor at this point.)

Contestant #3: Euro-Fer Iron Capsules

Details: Each capsule contains 300mg iron in the form of ferrous fumarate. Euro-Fer (from what I understand) is the generic version, but Palafer is the name brand for this supplement. The dose recommended to me was 1 capsule daily. Full specs can be found here.

euro-fer iron

Ding ding ding! We have a winner! The specialist I saw in January 2014 figured that the earlier doses had been far too low to have caused any substantial changes, so he suggested Euro-Fer iron which is available over the counter. (Floradix is available off the shelf here in Canada, and Genestra is also an OTC.) He warned that because the dosage was significantly higher, I might experience some digestive discomfort but this was totally not the case. For the record, he also said that refraining from running was totally unnecessary, so we’re pals. 😉

After only 1 week, I felt awesome. My cardiovascular capacity felt like it was back and while I was still taking it pretty easy in the gym, the buckets of sweat I’d initially experienced weren’t gushing out of my pores any more. Another perk was the cost – Euro-Fer is available for between $5-8 depending on where you buy it, making it a much cheaper option than the other two mentioned

Is it really working?

New blood work done around August and October 2014 showed that my ferritin was up from 4 to 12, putting me at the very bottom of the normal range (but at least I’m IN the range!!!) The evidence that it was working showed in my lab tests, but also in my race performance. I hit a new half marathon PR of 1:28:30 in June and continued to have some great races throughout the summer – a much welcomed feeling after having had such a crappy 2013 race season. My most recent test done in November showed another 12. #winning

Waterloo 10K Classic

 A note about types of iron

According to Anemia.org,

“There are two general types of iron supplements which contain either the ferrous or ferric form of iron. Ferrous iron is the best absorbed form of iron supplements. Most available iron pills contain ferrous iron. There are three types of ferrous iron supplements commonly found: ferrous sulfate, ferrous fumarate, and ferrous gluconate. While all three come in a 325 mg tablet size, each one contains a different amount of the form of iron used by your body, called “elemental iron”. When choosing an iron supplement, it is important to remember to look at the amount of “elemental iron” in each tablet, instead of the size of the tablet.” Source + read more here.

So why did the Euro-Fer work better than the others? The specialist I went to said that he’d seen much more success on ferrous fumarate than other forms of iron, and perhaps switching AND increasing my daily dose was what my body needed.

What about food?

Obviously, nutrition plays a huge role in one’s iron levels and health in general. My diagnosis shocked me initially because although I hadn’t been a red meat eater for about 10 years, I consistently ate lentils, chicken, seafood, beans, and TONS of spinach. (It turned out that my spinach consumption caused its own set of gut problems that seemed to do more harm than good.)

spinach and kale

The thing to know about plant-based iron-rich foods like spinach, beans and legumes is that they contain non-heme iron, which (as you may have guessed) comes from plants. Our bodies can still use it, but they don’t absorb it as well as heme iron, which comes from hemoglobin in animals. So while I was probably getting plenty of non-heme iron, my body wasn’t absorbing it. As you may have heard in the past, we’re not necessarily what we eat, but we are what we absorb.

lentil kale and tempeh saute

What dietary changes did I make?

First, I sucked it up and ate some steak. It was weird. My tastebuds didn’t know what to think of the foreign morsels in my mouth which I tried to hide amongst lots of vegetables (like in this stir-fry). But I did this because it was August 2013 and I had the Lululemon SeaWheeze Half Marathon coming up which I was desperate to get better for. My steak of choice was usually sirloin or eye of round, produced by Aspen Ridge. This company raises their cows humanely on a 100% vegetarian diet, free of antibiotics and hormones.

Ginger-Orange Beef and Pepper Stir Fry - Eat Spin Run Repeat

Since then, I haven’t been eating steak as regularly because truthfully, I don’t love it and my Euro-Fer iron supplement has been doing a good job. However, there are a few guidelines I still follow and would recommend to anyone facing the same issues:

  • Take the iron with a form of vitamin C to boost absorption (ideally a food source of the vitamin, not another supplement)
  • Avoid caffeine and dairy around the time of taking the iron as this hinders absorption. (So if you need to have your coffee in the morning, that’s probably not a great time to to do it)
  • Incorporate a variety of non-heme and heme iron sources into your diet. Obviously vegetarians and vegans will have a much harder time with this since heme iron comes from animals, but I still think eating a variety of plant-based non-heme foods helps. Mayo Clinic has a good list hereNote: Because I have a sensitivity to spinach, I keep my intake low and instead incorporate lots of other leafy greens like kale, swiss chard, collards, herbs, and lettuces. 

Vegan Lentil and Veggie Stuffed Peppers - Eat Spin Run Repeat

Where I’m at now

I’ve been taking the Euro-Fer ferrous fumarate supplement for nearly 1 year now, and feel 100% back to normal – and better. I’m not sure exactly sure if my iron was low prior to 2013, or if it just took a really steep hit in that spring half marathon. However, the lab tests and my physical performance in athletics has me pretty convinced that lots of progress has been made. While it would be ideal to boost my ferritin a little higher, for now I’m content with where it’s at and fully intend to keep an eye on this whole situation as I train for my first half Ironman this year.

running along the sea wall in vancouver

Phew. Now that I’ve written you all an essay, let’s flip the conversation over to you. I’d love to hear about any of your experiences with iron deficiency, regardless of whether you’re a runner or not.

  • Are there any supplements not mentioned here that you’ve seen success with? 
  • Have you tried anything other than supplements, such as iron injections?
  • Has anemia affected your ability to compete in athletics, or did it in the past?

My hope is that this post will be a resource for anyone dealing with a similar situation to the one I experienced. Your comments below will make it even more valuable, so feel free to go into as much detail as you like!

Disclaimer: Please remember that I’m not a doctor, and none of the content in this post is intended to be interpreted as medical advice. If you do suspect that your iron is low, it’s best to check with a healthcare professional before beginning to take any supplements etc. Thanks! 🙂