Ferritin levels.... the definitive answers???

  • Jim Kasten
    Coach
    Insider
    JIMKASTEN Edited
    I am looking for some one with a medical back ground with the answers to sevral questions.
    If Dr. Colter is out there hopefully he can jump in here.

    What is the exact name of the test you need to ask the Dr. to perform?
    Is the test different than testing for iron? [Similar to what they do for giving blood.]
    What is the levels when an iron supplement should be used?
    What level should iron supplements not be used?
    What are the best supplemnets to take?
    How much should you take?
    Should you take it in the morning or evening or both?
    Is the extra iron that the body does not need or uptake into the system leave the body through urination?....Or..... Does it stay in the body to some how do harm?
    Other than red meat what are some good natural sources for iron that teenage girls/boys might eat.

    We have girls taking a 65 mg Ferrous Sulfate supplement. Is this sufficient?
    Is the liquid version of ferrous sulfate better and where is the best place to purchase it?

    Thanks in advance.

    Jim Kasten
    Herculaneum High School
  • Terri Menghini
    User
    Insider
    btm2008
    @JIMKASTEN


    I am not a medical doctor but I do know the ferritin level can severely affect a runner. My daughter, Krista Menghini, was one of the top runners in the state and this past spring she was affected with a low ferritin level. She had great training in the off season and then beginning mid-March, she started to feel a little tired and was having difficulty getting through her workouts. We thought it was overtraining in the off season (she ran a half marathon in Jan.), so we started to back off on her training. Her times began to get slower and slower and she was running the 1600 30 seconds slower and the 3200 a minute slower than the previous year. The beginning of May she was really struggling getting through a race and was dizzy, tired, had very heavy legs, and had no energy on her last lap of the 1600.
    When Krista ran the 3200 in the beginning of May 1:15 slower than the previous year, it dawned on us that she might be anemic. She was tested by 3 different doctors who were only checking out the iron levels which were fine. Eventually (unfortunately only a week before districts) did one doctor finally test the ferritin level. All were done with blood tests. Her ferritin level was at a 35 and needed to be between 80-120. At least we knew the problem, but it was too late for districts. She took 350 mg of ferrous sulfate for 6 weeks before her level came up to a 77. She ran a race at the end of June (6 weeks later) and was only 10 sec behind her 1500 time. Krista had the energy to finish the race and have her kick at the end again. We then knew she was better.

    It’s a long process to get back, but an athlete will recover. She also had to take Vitamin C to absorb the ferrous sulfate. She would take all pills in the morning. Once she was back to almost normal, she cut back to 150 mg a day. Taking too much iron can be bad for you as well, so you should get it checked out before taking the medicine.

    I think each runner should be checked for this problem since it is very common and we found out many great runners had this problem and lost a year of competition. Eating red meat, spinach, and liver (yuck!) helps as well. My youngest daughter (age 13) is taking 50mg a day to prevent this problem.

    Terri Menghini
  • User
    jilo
    All good guestions that I have been wondering about myself.
    My child struggles with fatigue and unable to finish hard work outs
    and races due to weak legs and has even collapsed. Has done blood work, seen a neurologist, and gone to a cardiologist (EKG, echo cardiagram, exercise induced stress test). Has also had thyroid checked. Doctors have not found anything wrong.
    Drinks around a gallon or more of water a day. Usually 115-160 ounces.
    My child had blood work done and shows the following:
    These tests were done after season was over.

    Iron: 59 Normal Range 28-125
    Ferritin: 26 Normal Range 7-140
    Sodium: 138 Normal Range 137-147
    Potassium: 4.1 Normal Range 3.6-5.2

    The doctors say that all these are within normal range. However, it looks like you are saying that ferritin 26 could be too low for runners. I know that taking too much iron supplements can hurt your body. How do you know how much to take and what is the right iron supplement for you? The doctor only recommended taking a daily multivitamin.
  • User
    Insider
    bigbluesfan
    Our daugher experience the same problem this past fall her senior xc season. She had come off a great summer track season and starting having very tired legs when she would run anything over 2 miles. Everyone at first thought it was fatigue due to running summer track, however in September she collapsed after a xc meet. We checked her ferritin level and it was 7. She received IV iron and is continues to take 130mg to 260 mg of ferrous sulfate a day. She has her ferritin level as well as a iron profile drawn every 2 - 3 months. We were told she needs to be at least 50 for ferritin but 80 - 120 would be better. We are managing to maintain her around 80- 90. She also learned she needed to change her eating habits-- watch her milk intake when she is taking her iron pills -- it prevents absorption. It took until the state meet for her to truly feel like she was getting back to normal. She states now she can tell by how her body feels if the level is dropping.
  • Jim Kasten
    Coach
    Insider
    JIMKASTEN
    @bigbluesfan

    These posts are all good information but as we read through them you can see the issue I have. Everyone has a different number for normal and what is to low.
    I have been told by a very knowledgeable coach that a female athlete that trains hard and performs at her top level needs to be atleast a 30 for ferritin.
    Our runner had a 16 and struggled. Even after getting to a 21 around state she was not at top form. She took 65mg in the morning and a tablespoon of Geritol in the evening [about 16mg of ferrin]. She does take it with orange juice.
    I am still at a lose to know what to tell parents. It sounds like some are taking large amounts with no real side effects. But at what point do we know to back off?

    How often should they be tested?
  • User
    Insider
    bigbluesfan
    I have been instructed if a girl has no problems twice a year is ok and many recommend once a year. However, when the problem is diagnosis we were told monthly until the count is above 50 then go every two months until you can tell they are maintaining the level. Everything I have read states a female athlete should be above 50 however it is very individual of what symptoms the girls will have and at what level they feel them. Many girls are able to push their bodies at much lower levels don't realize the problem is ferritin because they are teenage girls-- parents need to be watching for other symptoms such as increase amt of time spent sleeping, falling asleep in school, inability to focus, wanting ice chips; the biggest problem is getting doctors to test and follow up in the best interest of the female or male athlete.


    We were told collegiately she will be tested at least every two months and more often if she is starting to show symptoms. Many programs start female runners on iron supplement as soon as they get to school. I know one program told us that 7 out of their 9 recruits where iron deficient.
  • User
    jilo
    Anyone know of a Dr. in the KC area that would understand low ferritin levels
    and negative impact on runners. Would like to go to someone that is more familiar with this scenario and what to look for in CBC and ferritin level results.

    When looking at my child's blood work results, I noticed that my child's RDW was considered high (14.2) with a normal range of 11.2-13.5. Research on the internet states that a high RDW along with a lower MCV (or even a normal MCV) can be an early sign of iron anemia. I noticed that my child's MCV was 83.8 with normal range 79.9-92.3. With a ferritin level at 26, I believe that an iron deficiency is a great possibility.
  • Max Storms
    User
    CelticRunner
    @jilo

    From my experience, 26 is far too low for a runner. A normal, sedentary individual would be fine at this level--they've no real need for incredibly efficient oxygen transport, and the biggest consequence for them would be fatigue upon climbing a flight of stairs.

    For a runner, anything below 50, IMO is too low. Some people react to supplementation differently--when I was low (17), I took 88mg of ferrous sulfate elixir (liquid) with a Vitamin C supplement daily for about a month and saw marginal gains (26). After another month of supplementation I was 56--at that point we stopped testing and I've continued to take 44mg of the supplement daily since then. The doctor told me that the normal "range" was 30-300, but for an endurance athlete, the lower end of this range isn't sufficient.

    While iron deficient, running isn't fun. Fatigue is continuous and compounding--it isn't a pleasant lifestyle.
  • Jim Kasten
    Coach
    Insider
    JIMKASTEN
    CelticRunner
    @jilo

    From my experience, 26 is far too low for a runner. A normal, sedentary individual would be fine at this level--they've no real need for incredibly efficient oxygen transport, and the biggest consequence for them would be fatigue upon climbing a flight of stairs.

    For a runner, anything below 50, IMO is too low. Some people react to supplementation differently--when I was low (17), I took 88mg of ferrous sulfate elixir (liquid) with a Vitamin C supplement daily for about a month and saw marginal gains (26). After another month of supplementation I was 56--at that point we stopped testing and I've continued to take 44mg of the supplement daily since then. The doctor told me that the normal "range" was 30-300, but for an endurance athlete, the lower end of this range isn't sufficient.

    While iron deficient, running isn't fun. Fatigue is continuous and compounding--it isn't a pleasant lifestyle.


    @CelticRunner
    Where are you able to buy the ferrous sulfate elixur [liquid]?
    The Walgreens and Shop n Save neither us do not caryy it.
    Thanks,
    Jim Kasten
  • Max Storms
    User
    CelticRunner
    @JIMKASTEN

    You can usually ask the pharmacist to order you a bottle at any local pharmacy or Walgreens/CVS type place. It usually just takes a couple days, and you can tell them to order you more than just the one bottle (it doesn't expire very quickly) to avoid having to go into the pharmacy too often. A bottle generally lasts me about 3 months (1 tsp daily).
  • Kim Colter
    User
    kcolter
    I agree with most of what has been said in the thread above. Measuring serum ferritin is the best way to assess total body iron stores short of doing a bone marrow aspiration (painful, expensive, and not necessary to diagnose iron deficiency.) I have reached the point that I would say that every female distance runner should be taking iron unless they are known to have a personal or family history of hemachromatosis, a disease in which thee is excessive iron storage in the body that can cause liver disease, diabetes, etc. Iron deficiency in male runners is less common, but not uncommon, and many young men need iron supplementation as well.

    Some confusion may arise with regard to the two ways in which the amount of iron can be expressed in a preparation. One way is to describe the milligrams of iron in each pill or tablet, the other way is to describe the milligrams of iron sulfate or iron gluconate in the pill or tablet. A 325 mg iron sulfate tablet contains 65 mg of elemental iron. I agree that Vit C, orange juice, increase the absorption of iron, and coffee and tea decrease the absorption of oral iron.

    With respect to what is an adequate ferritin level, I would say that anything over 30 is acceptable. I think some of the suggestions for optimal ferritin level in the thread above may be on the high side. At the National Distance running summit three years ago, I asked Dena Kastor's coach about her ferritin levels. The answer was that she was having them checked four times a year then, and they ran between 28 and 36. She won an Olympic marathon medal with these ferritin levels. Clearly, we cannot use the levels listed as normal in lab reports as the normal levels for runners.

    Those coaches and parents who have had their runners go to doctors to be assessed for iron deficiency and have had only CBC (complete blood count) or serum iron levels drawn can be justifiably frustrated. Iron is a cofactor for an enzyme that is involved in lactate metabolism. When rats in the lab are completely depleted of iron, but transfused to maintain normal blood counts, the rats can't race, and the rats can't clear lactate the way iron replete rats can. In talking with many iron deficient runners, they will tell you that they can do long runs, easy runs, even lactate threshold runs, and feel reasonably good. What they can't do is race. They can't race because they can't clear the lactate that race pace generates. These iron deficient runners who can't race will often not be anemic, and a hemoglobin and hematocrit will not diagnose the problem. (There will be some who will argue that it isn't really lactate that makes you say "uncle" when racing, but I don't think we have a better marker than lactate for what makes a runner drop off a pace that is beyond their training ability.)

    A significant problem is how we go about replenishing the total body iron stores of a runner that is discovered to be iron deficient during a racing season. It takes two to three months to replenish total body iron stores using the inexpensive oral iron that is available over the counter as iron sulfate (this is true for both liquid and tablet form.) For that reason, I think good times to test runners are at the end of outdoor track and at the end of cross country. This is when they are most likely to be low, and there are a couple of months before the next racing season in which to replenish. However, many times the low ferritin is discovered when racing isn't going well during a season. In the thread above there is reference to treating a runner with IV iron. It is possible to replenish iron stores in one day doing this. However, it is expensive, and carries a small risk of anaphylaxis, which in a worst case scenario can be life threatening. When I discovered my own daughter's iron deficiency (ferritin 16) after a lackluster district XC race, I considered doing this, but found myself saying that I couldn't accept even a small risk of anaphylaxis to make her able to race better. There is however, an oral iron preparation that is absorbed through a different receptor in the gut, the heme receptor (this product is made from stock yard blood, sorry for the gory details), that will replenish total body iron stores in a matter of weeks. This product is available without a prescription from Colorado BioLabs. It can be ordered by phone or on the web. I have seen several athletes raise their ferritin from the low 20's or high teens to 50 to 60 in three or four weeks of using the product called Pro Ferrin. 90 pills costs about 50 bucks if I remember correctly. This product will give a positive test for hidden blood in stool if that test is done on someone who is taking it (not something that young runners are having done, usually.) For any runner who is found to have low ferritin now, I would strongly consider using ProFerrin ES, the product from Colorado BioLabs, rather than the iron sulfate you can buy at the local drugstore. I realize that not all families can afford the more expensive product for their daughters/sons. I can't emphasize enough the need to try to prevent iron deficiency with supplementation throughout the year for female runners, and for male runners who have been shown to be iron deficient. As to which foods in the American diet are sources of iron, it primarily boils down to meat and breakfast cereals that are fortified with iron. Many young women runners eat little or no meat, menstruate, lose tiny amounts of iron every time they run by squashing red blood cells in their feet, having the sides of the bladder rub together, having the sides of the stomach rub together, etc. It is not uncommon for male runners who had adequate ferritins when they were running 40 miles a week in high school to become iron deficient when they start running twice that many miles or more in college.

    I'm out of gas and must stop typing. I hope I haven't made too many errors or typos in what I've written.
  • BRIAN GOSNEY
    User
    GOZRZX
    @kcolter Not to beat a dead horse. This product should be available loccally. May be need to speacial order. My personal bias, check with an indepent Pharmacy. My wholesaler lists 30 count Pro Ferrin ES retail price 31.84 plus tax.
  • Jim Kasten
    Coach
    Insider
    JIMKASTEN
    @GOZRZX

    Thanks to Dr. Colter and everyone that responded!!

    This is some good info and I can pass it on to my athlete's parents and to their family doctors.

    I appreciate everyone that put forth info.

    Jim Kasten
    Herculaneum High
  • Kim Colter
    User
    kcolter
    @GOZRZX
    I have no commitment to any source of the ProFerrin ES. Website for Colorado BioLabs has 30 tablets for $22, 90 for $54.75. Almost all athletes can take one a day without too much constipation. Two a day is possible for most. It really does restore total body iron stores faster than iron sulfate. If time is of the essence, as it is during a season of racing, I think there is a distinct advantage to the ProFerrin. If there are a couple of months before the season starts, it is possible to restore iron stores with iron sulfate. For maintenance of iron during the season, either product can be used.
  • Jesse Griffin
    Coach
    Insider
    griffinj12
    If an athlete already has ferritin levels that are good is it wise to take extra supplements? At what level without knowing for sure an athlete needs extra iron could it be toxic to the athlete?
  • Kim Colter
    User
    kcolter Edited
    @griffinj12
    Coach, my answer to this question would be different for young men and for young women. For women who are running high school or collegiate level of training miles I think that it will be rare for a woman who is not supplementing iron to be able to maintain enough total body iron to maintain a high level of performance. It's going to be a rare circumstance in which you can overdo the iron supplementation in menstruating runners. What seems prudent to me is to have young women take a 325 mg iron sulfate a day (presuming their GI tract tolerates it) and have them check their ferritin twice a year, perhaps at the end of outdoor track and the end of cross country. If the ferritin level is getting high (into the 150 or greater range) I would let their family doctor make suggestions about what to do with the iron, and whether to test that young woman for the gene for the iron storage disease, hemachromatosis. For young men, I would check ferritin twice a year on the same schedule, and would supplement those who have ferritin that is lower than 45. If they develop a ferritin that is greater than 150, I would have decisions about their iron supplementation be guided by their family doctor, and leave the issue of testing for iron storage disease to the doc as well. I have seen several young men, particularly those running a collegiate level of miles, have their ferritins be in the 20's at the end of cross country season. On a DIII cross country team that tested all their men at the end of the season, 50+% were under 30. This was a season in which a team that had great expectations had lackluster performances when it really counted in the conference championship and NCAA regional meet. A year later the same male team had their runners take iron supplements and had a much more satisfying performance at the end of the season. Admittedly, there are other variables, such as coaching decisions, that are involved in optimally peaking a team for the important races at the end of each season.
  • User
    jilo
    @kcolter


    From the earlier posts it appears that
    325 mg iron sulfate tablet contains 65 mg of elemental iron
    According to the ProFerrin Supplement info on the Colorado BioLabs website
    one Proferrin capsule contains 12mg of elemental iron

    If it is recommended that a female athlete runner take a 325 mg iron sulfate tablet
    daily (65mg elemental iron) during off-season to get her ferritin back up to a reasonable level before xc season starts, how how many capsules of Proferrin should she take daily during the xc season if she finds her levels are low and wants to get her ferritin level back up if time is of the essence? I was under the impression that one Proferrin capsule would not cause too much constipation but more than one capsule daily could be hard to tolerate.
  • Kim Colter
    User
    kcolter
    @jilo
    I should have addressed the difference in elemental iron amounts in the Proferrin and iron sulfate. Iron sulfate is actually rather poorly absorbed, most of it is coming out in the stool. ProferrinES is absorbed a bit better, through a different receptor in the gut, but there is still enough of it left in the stool that it also can cause constipation. People differ in their ability to tolerate oral iron. I find that many iron deficient runners can tolerate two of the Proferrin ES tablets per day, some are too constipated by two Proferrin a day. In general, I think the Proferrin is tolerated a little better from a GI standpoint than the iron sulfate is. I have personally seen both male and female runners take their serum ferritin from the low to mid 20's to 55 to 65 in one month of taking two ProferrinES tablets a day. I have not seen iron sulfate raise the ferritin that rapidly. For the runner who is discovered to be iron deficient at the start of cross country or track season, the Proferrin seems to raise the total body iron stores faster than the iron sulfate, and seems capable of raising the total body iron stores in time for the important races at the end of track and cross country.
  • User
    runner40
    @kcolter
    My daughter has struggled with low ferritin levels since freshman year in high school. She is now a senior and has just received her highest levels ever - 82. We have tried everything, liquid iron with oj, pro ferrin heme pills from Bio labs and iron infusion. Didn't have much luck with the Bio-lab pills, but she didn't take them on an empty stomach like she does with the liquid iron. We tried the Bio lab pills for 6 months and her ferritin went from the 70's (from an expensive iv infusion) to 18 in 3 months. Most of her high school career we struggled with low ferritin and low iron serum. I know it is expensive to get blood tests, but I think each athlete is different and a blood test once a month to check to see what is working is probably the best. We also added homemade beet/apple juice this summer. Maybe that's why she is finally at a great level. Ferritin levels matter and even when she was on the decrease at 30 ferritin levels and entering post season, she noticed a huge difference when she received the iv infusion. We have stuck with the liquid iron (Rugby brand from Walgreens), mix with oj and add 1/4 tsp of vitamin c twice a day on a totally empty stomach. She also follows a strict diet with healthy red meat, beans, brown rice, vegetables and fruit. No caffeine, no oxylates with red meat, etc. The hardest part is finding a doctor who is open to treating an athlete differently than a regular patient. The running community is the best place to start.
  • Kim Colter
    User
    kcolter
    @runner40
    Your post is most informative and valuable. I think it really points out how important absorption of the iron in one's gut is. The avoidance of tea and other sources of oxalate that inhibit iron absorption, taking iron along with a source of Vit C, and in your daughter's case, taking the iron on an empty stomach are all very important. Heme iron, iron that is bound to hemoglobin (blood) or myoglobin (meat/muscle iron)is absorbed through a different receptor and is absorbed much more completely than inorganic iron compounds such as iron sulfate. The precipitous drops that your daughter has experienced in iron are about the most dramatic I have heard of--it is valuable to know that such precipitous falls do happen.
    I can see why in a circumstance such as hers you would advocate for monthly testing of ferritin. In most circumstances I would think that testing either two or four times a year would be sufficient. I have been told by Joe Vigil, one of Dena Kastor's coaches, that she is tested four times a year, and won her silver medal at Athens with ferritins of 28 to 36 during the time she trained for the Olympic marathon. It certainly makes sense to test more often in a circumstance in which maintenance of an acceptable ferritin has been as difficult as described for your daughter.
    With such a precipitous fall in total body iron stores, I must admit that I wonder about the possibility of a runner losing iron more rapidly than usual. There are some people who have vascular abnormalities in their intestinal tract that leak red blood cells. I have seen some profoundly anemic people who got that way from the slow, steady, insidious loss of red blood cells into the GI tract.
    It is valuable to know of your daughter's success with liquid iron and Vit C taken on an empty stomach.
  • Tiffany Haines
    User
    Tiffhai
    I came upon this discussion because I was searching for answers about my own ferritin. I am 36 and have been a runner all my life. I ran cross country and track in middle and high school. Since high school I have battled iron issues. But after having three kids I was beyond exhausted and a doctor found my ferritin to be 7. My hemoglobin was normal. They gave me an iron infusion last June. Ferritin went to 330. Then after one year I depleted it to 22. I just got another infusion. They found no blood in stool sample or urine. So hematologist thinks I can't absorb iron. My question is can I not maintain ferritin simply because I run?? He doesn't seem to know. Thanks.
  • Kim Colter
    User
    kcolter
    @Tiffhai
    Menstruation and running both cause you to lose iron. Clearly you are losing iron more rapidly than you are absorbing it. Iron absorption can be enhanced by taking iron on empty stomach, avoiding tea or coffee along with it, taking Vitamin C along with the iron, and by taking heme iron which is absorbed through a different gut receptor than inorganic iron sulfate. Heme iron is the form of iron found in meat, and is the form of iron in the ProFerrin ES product mentioned in the thread above. There is one note in the thread that details how one user of ProFerrin could not replenish and maintain iron. I have seen excellent results with ProFerrin. If all of the above suggestions that enhance oral iron absorption do not enable you to keep your ferritin up, intravenous replenishment may be the only avenue open to you. Reduction of menstrual loss of iron can be accomplished with oral contraceptives, endometrial ablation, or hysterectomy.

    Menstrual losses of iron are difficult to quantify and vary from one woman to another. Women who are hypothyroid have higher menstrual losses, as do women who have fibroid tunors of the uterus or dysfunctional uterine bleeding. Many women experience higher menstrual iron loss at around age 40 or 41 when their estrogen levels begin the fall that continues until menopause. Most women who take oral contraceptives lower the amount of menstrual iron loss because they have lighter periods.

    I am curious about how many miles per week you run and how long you have been running.