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Iron Deficiency in HS Endurance Athletes

As coaches of the Sunset Cross Country team, we make a yearly case to the parents and guardians of our athletes to investigate the subject of iron deficiency. It is our belief that any athlete wishing to participate formally in high school cross country would be required to undergo an annual full blood test (CBC) as part of their routine physical exam to check iron levels in the blood. You may be aware that this is not a current requirement and we would never be so bold as to overstep our bounds as medical non-experts to make such a mandate for Sunset Cross Country. We acknowledge that it is a doctor’s role to advise families in medical matters such as these. We encourage all of our athletes to pursue the issue with their doctors and use this letter to make a case for doing so.


There are different measures of iron in the blood. The one that concerns us most as runners is serum ferritin (measured in ng/ml). Ferritin and iron are two pieces of the same pie. Ferritin is a protein containing iron. The primary role of ferritin is to store iron in the bone marrow, liver and other organs. Ferritin is like a support system, helping to form hemoglobin in the red blood cells, which carry crucial oxygen to the working muscles. Like muscle glycogen, another primary energy source, ferritin is a reserve – a bank account, if you will – that can be reduced or used up over time. Lack of ferritin results in lack of red blood cells and, in turn, lack of oxygen. Have you ever tried run­ning without breathing? Probably not. The body can’t do very much for very long with­out oxygen.


Low iron stores are problematic. Without getting into a lot of detail, iron deficiency (which is not the same as anemia) leads to declining performances, lower levels of energy, injury, and a variety of other medical concerns. In short, iron deficiency is not good for distance runners.


It is worth noting that too much iron (hemochromatosis) can be a bad thing. It can cause problems including liver damage, chronic fatigue, and irregular heart rhythms. Too much iron in the blood is rare and is often linked to disease – something that a doctor can determine – and a good reason not to handle iron supplements in ignorance.


Evidence suggests that iron deficiency is a common issue for a large percentage of high school distance runners, especially young females (picky eaters and vegetarians raise this likelihood even more). Please consider making the call to your doctor and requesting a CBC by name before school starts. When our athletes are tested, they often come back with low ferritin levels (30 ng/ml is generally believed to be the low end of the healthy scale for endurance athletes). Most of our runners will have supplemental iron in their diets. We encourage all of our athletes to consult with their doctors about best methods for iron supplementation in their diets specific to their individual needs. We can suggest some ideas that can be further discussed with a doctor.


Whenever getting a CBC, please ask for a copy of the full report. We welcome these reports and know how to read them. If for any reason you’re unsure about pursuing a blood test this season for your athlete, please reach out to us to discuss – we'd love to provide any additional information you might need/want to make a well-informed decision, including reference materials.


Your athlete’s health is our top priority.


Here are some links to other sources of information about iron deficiency in endurance athletes:

Iron Depletion: What you and your doctor need to know by Jess Hess, former head coach of South Eugene HS - succinct, to-the-point, and well-written

Low ferritin and iron deficiency anemia in distance runners: A scientific guide for athletes and coaches - a bit longer but full of great information to consider

Ironing Out the Details: Know the facts about ferritin and iron before deciding to supplement - a shorter and simpler read than the previous one, still with some good informationt to consider

Iron Level Upkeep For Runners - by Caitlin Chock, former HS 5000m national record holder, she fought a losing battle with eating disorders and, as a consequence, iron deficiency


How does one get more iron in their diet?

Regardless of whether or not an athlete has a blood test and tests low for iron levels, it is widely agreed that distance ath­letes should pursue diets containing iron. Shellfish and liver are the two best sources of iron. Not everyone likes that stuff. Next on the list is red meat (beef). Dark turkey meat is another ex­cellent source. These are all sources of heme iron (the best kind) but there are some other ways to get iron into the diet (all of these are vegetarian options, somewhat ranked in order of po­tency):

1. Iron-rich cereals for breakfast – “natural varieties” don’t have any added iron

2. Cooked beans and tofu (canned beans are pretty good, too, though not as rich)

3. Pumpkin, sesame or squash seeds

4. Baked potato (something about the baking makes the iron more readily available)

5. Egg noodles

6. Nuts (including peanut butter!)

7. Spinach, bell peppers and any other DARK green vegetables

8. Brown rice, lentils

9. Pasta, bran muffins


A few other ideas:

1. For iron-rich vegetables like spinach, beans and lentils, eat LARGE portions be­cause plant proteins are not “dense” sources of iron like red meat.

2. Cook with a cast-iron skillet if possible. The disappearance of these from kitchens might be the single biggest reason why iron deficiency has become an issue over the last 30 years.

3. Avoid caffeine, which interferes with iron absorption: no tea, no coffee, no soda. Cal­cium and magnesium are also iron inhibitors.

4. Couple an iron supplement with Vitamin C to improve absorption. Doing this as part of a “bedtime routine” is a great way to make supplementation a daily event.


As always: any questions? Just ask!


-Coach Neeway

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