Cheeky Run Club
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Cheeky Run Club
Why you should probably get your iron checked
Happy Monday Cheeky friends!
This week, we spoke with the wonderful endocrinologist Dr. Izzy Smith about (drum roll please)...IRON! We discussed the importance of iron in daily life and running, how to know if you’re low in iron, and what you can do to help your levels.
At the end of the episode, one of us reveals we were prompted to get a blood test after speaking with Dr. Smith aaand let's just say we're glad we did.
We also have a very special announcement for our listeners who live near Sydney for International Women's Day!
We hope you enjoyed this week's episode..let us know <3
LINKS:
Dr Izzy Smith’s Instagram here
Sign up for the Nike event here
Follow us wherever you get your podcasts + Instagram, Tiktok, Phoebe's Strava + Anna's Strava, and join our Strava community 🩵
Music produced by Hugh Raper. Logo design by Michael Cotellessa. Podcast edited by Kiara Martin.
CHeeky Run Club recognises that every day, we live, work and run on Aboriginal land. This This episode is brought to you by Nike's After Dark Tour. Join us and sign up for the Global Race Series, starting in Sydney on April 12th. Welcome to Cheeky Run Club, the social running podcast and community for your everyday amateur runner. Hello, Anna. Hello, Phoebe. And hello, listeners. I don't know if it's an understatement, but I think our main topic for today might change your life. It might. Listen closely. We talk about why many female runners are often putting standards around what actually qualifies as low and what the goal should be. And how to get on top of it if you common misconceptions that blew our mind. One of us has gone on a bit of a journey to understand their own iron levels. So, we'll finish with a little bit of a deep dive there too. But first, as always, our notable runs of the week. Anna, can you give me, I want to hear about your best running related experience this week. Well, for the first time in many weeks, it's not a swim. Well, is it a run? It's a run! Yay! It's this morning's run. Oh. We, uh, went for a run with of the pods, Mel. Uh, it was her birthday today. Happy birthday, Mel! Happy birthday birth to you, young Melanie. and we all went for a run together. We did. There was maybe about ten, eight, ten of us. Mm hmm. Ted was there. Ted the token boy. our Anastelle was down from Sydney, so it was really nice to see her. And I just love Close friends birthdays. Yeah, so happy because you just get to celebrate them for a day and I feel like it makes you reflect on how special they are to you as well. It is, yeah. A little bit of, I don't know, just like reminiscing of what's going on throughout your friendship. and yeah, it was a stunning morning. We ran around Falkner Park and the river. The sunrise was so nice, because it was very warm. Yeah, it was. But it was it was like 26 degrees at 6am. But I don't know about you, but I felt like I was treasuring it because it's going to get quite cool in Melbourne over the next couple of weeks. so yeah, and then we had coffee and birthday brownies. Birthday brownies. And I pretty much skipped into work. Oh, so lovely. That was a great morning. I agree. what was your, also your shout out today for making birthday brownies for Mel. Yeah. Yeah. They were, they were really good. we did some artist work with M& M's. Maybe we can post a photo. Yeah, and we did learn that I have a Yeah, it was actually quite interesting to watch because you first tried to write happy birthday and then you realize the H is taking up maybe like a quarter of the brownie and then we're like okay scrap that we'll try and write Mel and then you did an M that was so big that I had to like squeeze the EL and then you said I'll put a love heart down the bottom and I watched you start to try to do it I was like how much room do you think you have? And it took you putting down half the M& Ms to realize like, huh, it's not gonna be, I was like, it's like, she's really not, she's really not getting this. How, what was your best running adjacent activity this week? Okay, my best running adjacent activity was not a run for me. it was a ice bath sauna session. So you look surprised I just told you about this. Anna literally just did a surprised expression of it. Even though listeners definitely can't see your expression. But I did before tell you that I went to this last night. But I didn't give you any details so I'll fill you in on it now. I went to this, what would you call it? I guess, uh, heaven. It's this old warehouse that's sort of inside, outside. Yeah, mostly inside. But it feels a bit outdoorsy. Yeah, it's got heaps of indoor plants and it's really open it's called Inner Studios, it's in Collingwood. It's got a yoga studio out the back and then it's got this massive ice bath, which is freezing. Like it's actually way colder than most ice baths that I've been to. Apparently it's at four degrees and you can feel it. I reckon I'm normally okay with ice baths. Ice baths, but I really, it was really cold. And then there's a warm bath, which is also beautiful and big. And then a massive sauna, which is so nice too. and I went with our friend Claudia and we did a yoga session. Did you know Claudia is really good at yoga? she was in the row behind me because we both got there quite late and we're in different spaces and I was peeking at her a little bit. Yeah, you just said you do, you know, and I was like, Oh my God, she's legit really good. Yeah. I was like, I didn't know this about you. She was, yeah, she was getting it anyway. He'd do a yoga session and then he'd have 45 minutes of ice bath and sauna. And the yoga was fine, actually, it was just a fine yoga session. But the ice bath and sauna and bath afterwards was the nicest thing I've done in ages. it was sooo relaxing. It was such a good way to end the day. It was actually like, as I say, a very cold ice bath and a very hot sauna. so nice, it's also just a quick tip for any listeners in Melbourne that are keen to go, so it costs 45 to do the sauna ice bath session. But it also costs 45 to do a yoga session and then class on up. So, yeah, so you may as well do that one. That's an excellent idea. I honestly didn't love the yoga class. I think because I'm used to doing corporate I'm kind of going to endorse it. I don't know. Okay. but I'm, I'm not sure. Yeah, I've done it there and it's been a year ago. No, it wasn't Yin. Okay. It wasn't Yin. It was like strong or something like that. I think I'm used to doing yoga in a heated space in core plus, and this wasn't, and I could not believe how much harder it was to get into positions. Like I was so much stiffer. Yeah, I think so. but anyway, it was, really nice. And I'm kind of annoyed because I've just moved to this new gym, which has an ice bath and sauna, but this ice bath and sauna are way nicer. So yeah. Honestly, at this stage, I might. Tell me about your worst running adjacent experience this week. That's so true. Wow. Maybe Wednesday swimming, but we went after work to the beach, it was heaven, that was like, Oh yeah. Running for top. Wow. I went for a run with our girlfriend Chloe on Tuesday morning, which was so nice because I haven't caught up with her in a little while. Oh. I also went for a run, it was really nice, I just don't have a, I mean, my only negative was that I really wanted to run on Sunday. But I'm not allowed. Um, I think I'm finding it a bit, uh, quite a bit easier than I was a few weeks ago. It's been since December, since early December, so it's actually been quite a while now. I think purely just because you adapt and it becomes your new normal. So it's just kind of, it's just what you're used to. Whereas at the start, going down to that, and especially after just being injured and recovering and then, being told to stop running as much. So, I feel like at the moment it's okay. I do still really miss it. I am not on Strava because I just get Yeah, so do you just intentionally, have you deleted it off your, or you just don't upload anything to it anymore? I just haven't gone on it, so I don't, I don't know if anything's happening. It wouldn't, because I think I have to open it to further things. Oh really, okay. But I just don't go on it. Yeah. Yeah. Fair enough. Which was kind of hard to get into the pattern of it originally, but now I'm just I'm just used to it. And I feel like if I went on it, I would just be like, oh, I would want to do that. Yeah, maybe I'll start posting some rogue things in the, um, cheeky group. You'll have no idea. There'll be no one to pull it off. Yeah, you'll get back on and be like. If she goes rogue, you know what's gonna happen. Yeah, hee Really enjoying the book. Are you? Yeah, and I think Ted just gives a whole new That's so nice. I actually have a purpose to walk. Yeah, that's the other Because I'm like, if you can't run, maybe we'll just try and do everything else that you love about running. So, like, go to coffee, and talk That's that kind of vibe. Um Yeah, I'm like, Hey guys! Here for my coffee and chats. Yeah. Oh, my worst was unfortunately my long run also with Claudia. So double shout out for Claudia. She gets best and worst. I know she's a bit of a star. so star. So we did our long run on Sunday together. On the one hand. It was a beautiful morning. Like It was stunning, sunny, clear. Sunny and clear. No wind is what I meant to say. It was sunny and still and we ran through trails. Yes, you know what? Not raining. However, as soon as I started running, I was like, I don't feel good. I feel, in fact, really bad. And I know, I spoke last week about how I actually skipped a session'cause I just was feeling really rubbish. Well this was only a few days after that and I still was a couple Ks in and my heart rate was so high I felt ex, like I felt, felt physically so hard even though I wasn't running fast. And so I got to clubs and I was like, oh, I probably won't do full longy but let's just run and chat and look, turn around. But then I looked at my watch and we'd been going for an hour and she was like, we better turn around. So I actually ended up. Still doing a full long run, but I was so cooked by the end of it. I felt just like It's hard to explain how like fatigued I felt and I felt really frustrated because I don't know. It's just frustrating. I'm like, well, I feel like I should be getting fitter. Why should this feel so hard? Missed the session thinking this would be a good week. Iron conversation we had with Izzy, which was before the weekend, I went and got my blood tested. And so I, in the back of my mind, I was like, maybe I'm finally going to get an answer. And we'll leave you on that cliffhanger. This is huge. This is, no, no. Okay, if you're tempted to skip through the chat, I understand, but don't skip it because it's so interesting. Should we, should we get into it? I reckon. So, we are so excited to welcome Dr. Izzy Smith to the podcast today. Izzy is an endocrinologist, which for those who aren't aware, it's a doctor who specializes in. Diagnosing and treating conditions related to the endocrine system, which is made up of glands that produce our hormones. So she's also had a strong focus on women's health and athlete care. Dr. Smith is the representative of the Endocrine Society of Australia for Women's Health and on the Reproductive Life Clinical Advisory Committee. Not only has she worked with top organisations to contribute to guidelines on female athlete health, but she's also become a trusted voice for women everywhere, accessible, trustworthy, educational content on Instagram, where she does actually break down really complex health topics with clarity and in a highly actionable way. Yeah, we might link her, to the show notes because highly, highly, highly recommend to follow. Yes, definitely. she is also a runner herself with a passion for ultra trail games. She joined us to talk about all things iron. We absolutely love this conversation. If you haven't picked that up already, we learned so much and we hope that you do too.
anna audio:Welcome Dr Izzy Smith to Cheeky Run Club. Very happy to have you here.
Izzy:Thank you. I'm excited to be here guys.
anna audio:to kick us off, you're obviously a mad keen runner like ourselves. So we just wanted to know, can you tell us why you run?
Izzy:I got into running probably to not have a complete mental breakdown during medical training and to keep some reminder that there's a whole other world out there beyond medicine. And that evolved to a real love of the running community and love the structure it brings to my life. And also I used to get so stressed with medical training that It was a good way of me not going and drinking my stress on a Friday night, but going to bed early and getting up for a Saturday morning run group.
phoebe audio:Yeah,
anna audio:Yeah, Much healthier option.
phoebe audio:Keeps you accountable.
Izzy:Although sometimes, especially when I'm training for a longer event, I find myself on a Sunday in my pajamas ordering Uber Eats and having a snack, thinking this is exactly what I used to do when I was hung
anna audio:Yeah.
Izzy:And now I'm doing the same thing, but no, I, um, I love running for, lots of different reasons and yeah, very grateful to have found running.
phoebe audio:Oh, love it. Well, thank you for sharing and thank you so much for joining us today to have a chat about iron. We were saying just before, we are so excited to have this chat because iron deficiency is something that we've both struggled with along the journey. So we're excited to learn a little bit more. To start off, can you tell us what actually is
anna audio:iron?
phoebe audio:Yeah,
Izzy:in our body is that it makes up hemoglobin, which is our red blood cells that carries oxygen around our body. Iron is actually a metal. We discussed offline it is number 26 in the periodic table, which you know, might come in handy for a trivia night one day. Um, but so it's a metal and obviously it's big role in our body is being in here hemoglobin, which is important for carrying oxygen to our tissues, including our muscles. So we can make energy and run. But iron actually has lots of other roles in the body. It is important for our immune function. So when we're low in iron, that is part of why we're more likely to get mild coughs and colds. Iron is important for cognition and thinking. That might be why we get a bit of brain fog when we're iron deficient. Also important for energy production, and the main component of something called myoglobin, which is like our muscles hemoglobin, which stores oxygen, again, to help us, exercise. So, another reason why, even if our hemoglobin might be normal, we might not perform or train as well when we're iron deficient. Iron has lots of different roles in our body, and very important for athletic performance.
anna audio:is it any more important for endurance runners, to, shorter sports or, team sports?
Izzy:I guess the main thing to point out is that endurance athletes are more prone to iron deficiency. So maybe not that. shorter sports don't need iron and it doesn't have any critical role in their performance, but they don't run into all of the problems that endurance athletes do with, iron deficiency. You could theoretically say that endurance sports, we are using less of our ATP and more of our kind of oxidative, energy systems, but that's getting pretty theoretical. Anyone, you know, a shorter sport athlete who's iron deficient is also going to feel pretty crap.
anna audio:Yeah.
phoebe audio:And how do we actually get iron? Yeah.
Izzy:Yeah, so we get iron from our food. there's two main sources of iron. We talk about heme iron, which comes from, animal products and meat. And then there's non heme iron, which is in, vegetables, plants, fruits, that type of thing. Something to know is that our body doesn't absorb as much of that non heme iron. So when we're having dark green leafy veggies We're not able to absorb as much of that iron So we need to eat more of those high iron source foods if we're getting them from plant sources But yeah, we can't make our own iron. It's something we have to get from our diet
anna audio:so does that mean I read in an article that the, iron equivalent of a hundred grams of, I think it was lean beef steak, was three cups of spinach, cause they had the same amount of iron in it, but does that mean you actually have to eat more than the three cups because your body doesn't absorb it as well?
Izzy:Yeah. So we absorb about 35 percent of heme iron. So let's say we ate some meat of the iron in that meat, we could absorb about 35 percent of it. That's the maximum our gut can absorb. Whereas for non heme iron, we can only absorb about 20 percent of it. So yeah, you do need to eat more of those plant based.
phoebe audio:Yeah.
Izzy:It is something to take into account for, plant based or vegetarian athletes when, factoring in their iron. But I would say the other thing, we really need to test our iron because, some things like, dietary calcium. Patients say to me, what's the best way to know I'm getting enough calcium? I go, well, we look at how much calcium you're eating. Whereas with iron, there is so much variability in absorption. That, and, I would firstly just put my hand up and say I'm vegetarian for ethical reasons, so I don't eat, iron from meat. And interestingly, I've never been iron deficient. I have regular menstrual periods, and I've got friends who eat lots of meat, and need iron infusions, and I'm obviously really good at absorbing iron, and that's probably a genetic thing. We'll talk a bit about iron absorption, because it's regulated through, something called hepcidin. But there is a lot of variability in iron absorption between individuals. So it's not something you can just, monitor your iron intake and know you're getting enough. Really, with endurance athletes, I would say you need to have it monitored. Like,, blood test done.
anna audio:Yeah, because I was just saying to Pheebs off mic before, like I eat a lot of red meat, but I've got celiac disease. And I don't tend to absorb the nutrients, but are there other, factors that can contribute to iron absorption?
Izzy:celiac disease is a common, uh, Um, you know, If anyone has iron deficiency, they need to be screened for celiac disease. There are some other, conditions that are pretty rare. They're associated with minor malabsorption. If someone had one cystic fibrosis gene, sometimes their, GI absorption is not so good, but yeah, it is. A genetic, factor of, why some people absorb iron better. It's also to do with the other foods that you eat. We know iron is better absorbed if there's some vitamin C present and then some other foods like, coffee and tea and, slightly negatively impact iron absorption. So also the other foods that you eat your iron with would be part of that.
anna audio:Yep.
phoebe audio:so interesting. I know you said not too many dietician field related questions, but is there iron in eggs?
Izzy:I dunno, the iron in eggs off the top of my head too, or my favorite iron.
phoebe audio:a vegetarian, you knew.
Izzy:Yeah, no, my favorite iron source is Milo. uh, Milo the drink.
phoebe audio:Yeah. I love Milo. I've got
Izzy:It's quite, you know, I always joke when I have a Milo, especially if I'm doing a lot of training, it's like, this is a health food for me right now. But,
anna audio:This is a
phoebe audio:a supplement. Yeah. We were obviously just talking about how, there are factors that impact absorption. But generally, how or why does someone become iron deficient?
Izzy:Yeah, so it would be that your body is using more than you're getting. And the reason why endurance athletes are so prone to iron deficiency is a few things. One is that often endurance athletes have a state of relative energy deficiency. So they're just not getting enough total calories. And therefore, if you're not eating enough, just from a ratio wise, you wouldn't be getting enough iron. Then, also for women, they lose, some blood every month if they've got a menstrual cycle. endurance athletes then, we actually lose a bit of iron when we sweat. So, if we sweat, we lose some iron. Also, endurance sports cause quite a bit of inflammation in the body. And we should talk about hepcidin. But, the inflammation in the body from sports can negatively impact the iron absorption. And then also, it's called foot strike or hemolysis, where the sheer force of activity and running, especially some of our older red blood cells will, break. So there's,
anna audio:heard of that.
Izzy:yeah. there is a, you know, foot strike hemolysis, which they noticed in, people marching in the army, which runners would have as well, but there's, yeah, so there's lots of different factors for why endurance athletes are prone to iron deficiency. it's also in some other sports if they're, you know, weight based and, you Carry on a lot about that total caloric intake because if you're not eating enough, you also don't recover as well, and then you've got more inflammation in your body and that impacts your absorption of iron because you've still got levels of inflammation. So it's. Kind of this whole system, of, you know, low energy availability causes lots of issues and it is common in, so many endurance athletes, it's about 50 percent have, low energy availability. Yeah, and it's often by accident. It's just, it's hard to eat enough if you're running 120k's a week.
anna audio:Yeah. So if you're an endurance athlete, but like a long distance swimmer or cyclist, you're like going by the, what is it, hemolysis, I don't know where I was going with that.
phoebe audio:going with that. Hemoalysis.
anna audio:So you're probably less likely to become iron deficient.
Izzy:Slap, to be honest, the foot strike hemolysis is Most likely the most minor reason why endurance athletes it's more to do with the energy availability, the sweating, the inflammation. but running does put a lot of load on the body, compared to some other sports.
phoebe audio:And 50 percent is that, more common in females than males then, based on what you were saying about like menstrual cycle impact?
Izzy:It's really interesting because women's sport generally is so under researched. But the one part that is better researched, I would say, is energy deficiency states because of the whole female athlete triad, which was losing a period, bone stress injuries, and you know,, anorexia, which they've renamed because they've said it's not just in women. It's in men too. And now it's relative energy deficiency in sport. And men aren't studied as well as the female group about energy availability because they don't have that warning sign of losing their periods. I am not actually up to date with the evidence on men, but I look after a lot of male athletes with osteoporosis and they are completely oblivious to how profoundly low in, energy availability they are. And often I see them and I go, you're just not getting enough, they'll have low testosterone, low iron, their performance is dropped, they're getting coughs and colds. It's really common in male athletes as well.
anna audio:So I guess in a sense, we are kind of lucky that we almost have that easy sign to
Izzy:Totally, yeah.
anna audio:awry. Yeah.
Izzy:you know, often there's all of this stuff to do at the moment about menstrual cycle tracking, contraception performance. Really, there's not that much evidence to say, menstrual cycle impacts performance, that much as a broader group. But I said, the real benefit of having a recomme menstrual cycle is having your period as that marker that your body is, relatively well fueled, relatively well recovered. It's not perfect. You can still be under fueling and maintain your period for at least a few months but it is a really beneficial side, as a whole
anna audio:Yeah. And then you, you touched on how menstrual cycles impact iron levels. Is that purely just because you're losing blood?
Izzy:mainly, yeah, yeah, mainly you would You know, different parts of the menstrual cycle our hormones can impact our Baseline levels of inflammation slightly and that will have a slight impact on iron absorption But really it's that you're losing You know, 80 mils of blood per month.
phoebe audio:What about for, and I mean this is probably a massive topic in and of itself, but just to touch on, pregnancy, postpartum recovery, how do they affect iron needs for women, or levels?
Izzy:So I look after quite a few women who get stress fractures When they're breastfeeding. It's a perfect Recipe for injury at that time and I explained to them you have made all of your baby's blood From your body and you know, you've made all of your baby's bones From your body and if you were undernourished in any way and she's continuing to do that When she's breastfeeding because the baby is still having all of its nutrient supply. It's growing completely energy wise from the mother so it actually uses more nutrients and more energy to solely breastfeed a baby than during pregnancy because You're, you're still providing all of the nutrients, but rather than the baby being the size of a plum or a large mango, the baby is a big baby. So there's physiological mechanisms in place to ensure the baby will grow and get enough nutrients. So it will take the nutrition from the mother's body. And that's why we see bone density drops, percent in pregnancy and breastfeeding. And that's why I get a lot of patients with stress fractures in that time. Sorry, you can tell I'm a bone girl. I keep trying to get the topic away from iron to bones. Um, but, uh, I say the perfect recipe is for women in that time. their reproductive hormones drop when they're breastfeeding. They're really low. It's like having, functional hypothermic amenorrhea. Their babies sucked all the calcium away from their bones. Their biomechanics have changed from pregnancy because of the impact on your, tendons and joints stretching a little bit, and you've done way less volume. And so people are like, yes, I've had the baby, I can get back into running, and it's a really high risk stress fracture period, and of course it's a high risk iron deficiency period, one, because they've grown the baby, and often, in a vaginal birth, blood loss is around 500 ml, and in a cesarean section it's around 1000 ml. Women usually have, five liters of blood. So if you're losing 10 to 20 percent of your blood volume in that period, and that's, I'm not, I don't often recommend iron infusions unless someone's anemic, but definitely in that early postpartum state, especially if she wants to have another baby in a year or two, I do say there is a really beneficial role for iron infusions.
phoebe audio:Hmm.
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phoebe audio:I'm keen to hear a little bit more about what happens if you are deficient, like what does that mean? And so maybe just start with What would be some maybe early signs or symptoms of iron deficiency that athletes should watch for?
Izzy:that's a great question because there is definitely a range of how iron deficiency would impact us. And then that also means there's a range of how aggressively we should treat it. maybe we just talk a little bit about how we test for iron deficiency. And what the numbers mean, because that will help me explain the different phases. When we test for iron deficiency, the levels of iron in the blood aren't actually accurate. We look at something called ferritin, which is a marker of our stored iron. Ferritin is pretty good at predicting low iron. So if you have a low result, that's a true result and you are low in iron. But ferritin can falsely be elevated in a setting of inflammation. So if you had run 40Ks that morning and went straight and got your blood test, your ferritin would be falsely high. It's called like an acute phase reactant. So whenever I tell people to get their iron studies done, I say do it in the morning When you haven't exercised, maybe preferably if you haven't trained the day before and before eating because they can all impact our iron results. But ferritin is what we look for. And ferritin.
anna audio:sorry to butt in, but what actually, what is ferritin?
phoebe audio:Ferritin
Izzy:is like a marker of our iron storage and because we store iron in lots of different cells and so ferritin is in our, some of our immune cells and so it's a marker of our iron stores. So ferritin, we say the normal range is, 30 to 200 or 30 to 300. In menstruating women, I rarely see it above 100, but we usually say deficiency is below 30. But for athletes, I want their ferritin to be more than 50, as there's been some pretty good studies a randomised, controlled, blinded study, where they give one group of people iron supplements and another group of people placebo. And they've shown that athletes feel better, and I think it wasn't actually female athletes specific, it was just females they were looking at, feel improved energy once they get to a ferritin of 50. So even though we say officially deficiency might be 20 or 30, actually having a ferritin of more, around 50, is good for, not having any symptoms. So I would say those early, you know where you might have a serotonin of 30, 25, 35 maybe you feeling a little bit more, less powerful in your training, not feeling as good. That would be the main one. I think you, you're not going to have immune impact benefits then, but that, not feeling as strong, not feeling as powerful and energetic at a ferritin of around 25, 30. And at that point, that's when you'd think maybe I need to increase my, if you've got it tested, I need to increase my iron rich foods. Maybe I consider a supplement. I wouldn't go and get an iron infusion because you have a ferritin 35
phoebe audio:interesting what you say about,
anna audio:50
phoebe audio:is maybe a better level to aim for. I've, I don't think my ferritin level, has ever been above, 30
Izzy:yeah, because if I had a So if I was young, one of you guys is my patient and your ferritin was 30, I'd say let's supplement one supplement three times a week and check it in three or six months and try and get that ferritin above 50. And I have some patients that I just have on maintenance two iron supplements a week just to try and keep it around that level because they gradually teeter down.
anna audio:I was listening to this podcast the other day that said, I don't know how long ago, but our health parameters have kind of got more unhealthy. So it used to be considered that an, a ferritin level below 50. Was low, whereas now they've reduced that to 30. Is that, is that true?
Izzy:different labs have different reference ranges. So some will say a ferritin of 15 is normal. Some will say, uh,
phoebe audio:Oh, wow.
Izzy:The way they calculate reference ranges is usually based on standard deviations in a healthy population, getting a bit sciencey, but they will look at what is the normal range across a population.
anna audio:Yeah,
Izzy:There's a lot of, it's hard to say, people will talk about, optimal verse deficient and there is definitely, that is, true. Vitamin D, they say cutoff is 50 and that might be based on. Um, at 50 we know calcium absorption is impacted, but I want my athlete's vitamin D to be 90. So for some, there would be science and reason for why reference ranges might have changed maybe, with a ferritin below 30. Cause the other thing is if we made that ferritin deficiency 50, we are going to be screening five times as many people for bowel cancer because they've got low iron.
anna audio:yeah, yeah.
Izzy:And yeah, so you know, there's iron deficiency is something that makes me screen for bowel cancer, especially in someone who's not menstruating. And that's where medicine is not just, medicine by numbers. It's about having experience, clinical acumen, being able to look at the bigger picture. So I'm not going to worry that my female athlete who's ferritin is 25. I'm not going to go, you need to go and get a colonoscopy for bowel cancer. So yeah, so there's, the reference ranges are a big conversation in themselves, and they're not perfect, but also that's the clinician experience. And again, treating the person in front of you.
phoebe audio:ferritin. What other kind of iron markers are there beyond
Izzy:saturation and that's a good one because let's say your ferritin, and there's a disease actually where we absorb too much iron, it's called hemochromatosis, and that marker, hepcidin, that iron absorption. Their hein doesn't work. Say they absorb all of their iron from their food and they can act too much. Iron is bad. It, will kind of overloading organs like the pancreas, the liver. People can get, bronze skin, cardio problems with their heart from too much, iron overload. And sometimes it's hard to know do they have that disease or do they have. High levels of ferritin from inflammation from Maybe drinking too much alcohol or liver disease and so in that setting their transfer and saturation will be normal So transfer and saturation is you know, it's looking at the kind of saturation Oh, you gotta test my physiology. I'll be, I'm going to be up front. I don't know it completely. It's been a long time since I did my, physiology exams in specialist training, but the saturation is really good for helping, you know, if it's a true iron deficiency versus true elevated iron. As an example, I recently went to Nepal and I was at altitude for quite a long time and I've never been iron deficient and I got my blood test done. my ferritin said it was 10 and I was like, Jesus, I am really iron deficient, but my transferrin saturation was totally normal at 25%. And I realized I'm not iron deficient. I've got increased plasma volume from being at altitude and I had this dilutional low ferritin, but actually my transferrin saturation is normal. So that's just a, a third fee and I rechecked it in a few weeks and my ferritin had gone back to 40. So the transferrin saturation is another marker of looking at the kind of overall iron, levels. And it helps us know if the ferritin, I think of it as, is this ferritin a true result and how significant is the iron deficiency. If you have a low transferrin saturation, you're more likely to also have a true iron deficiency with that low ferritin.
anna audio:okay. And,
phoebe audio:I know we've spoken a little bit about hepcidin, so it sounds like that's the best indicator of how well you absorb your iron. Can you get that, I mean, is that right? But then also, can
Izzy:You, you don't get it tested in laboratory research settings, they will test it, but it's not part of basic, iron studies testing. I think I've talked about hepston because it helps us understand about iron absorption. So I usually tell my female patients. If they, for example, we talk about, you know, you've got mild low ferritin, maybe some mild symptoms, but you don't need an iron infusion or anything. I would say take an iron supplement on alternate days because when we take an iron supplement, it increases our hepcidin, which kind of blocks our iron absorption. So if we take iron supplements every second day, That second day the hepcidin drops. We take the iron supplement the next day. We absorb more of that iron and It means that the net overall iron absorption If you've got that mildly low ferritin, but not, significant anemia the actual iron absorption is about the same if you take it every second day versus if you take it every day and That makes it cheaper and a lot easier in our gut because iron supplements can cause constipation and lots of yucky
anna audio:yeah, I've been doing it all wrong. I'm on supplements, but I take them every day and yeah, they aren't very kind on your gut. So I, that would be so nice. I mean the day of reprieve in a sense,
phoebe audio:Sorry,
Izzy:I recommend the iron, I shouldn't recommend a brand because it makes me seem like I'm working for them, but I recommend the iron multifer, which is, made for pregnant women, and it's targeted as being less tough on your guts. So I often do iron, I tell people iron multifer every other day and usually it's better tolerated and it's half the price because the supplements aren't cheap, they're around a dollar a day. And if you're needing to take that for, six months of the year, it's time to add up just to add to the expense of running as a sport in general.
anna audio:pop that in the show notes, the link for
phoebe audio:Multiver.
Izzy:The liquid iron as well, and as well food. I think runners, anyone who's running a lot, should probably see a sports dietitian and get some professional advice on, I saw one and she's like, Izzy, you're just not eating enough protein. You need to stop having pesto pasta for dinner every other night. If you're doing weights twice a week and running five times a week. And I think seeing a sports dietitian and really focusing on food, having the iron rich foods on your, print out on your fridge is, we should always think of food first approach. And trying to get iron from our food, then iron supplementation. And if that doesn't work, there is a role for iron infusions. Iron infusions are usually, safe. They can sometimes cause a low phosphate. So that's why I do get concerned when someone has a mildly low ferritin of 30 and they just go straight off for the iron infusion. I'm like, you're not anemic, you don't have symptoms. Let's work on your diet because the iron infusions can cause a liver reaction. They can cause a low phosphate. It's quite a complex mechanism, but the low phosphate can make people feel really rubbish for weeks. And, the other thing is, it's much better to try and work on your diet and have your iron level stable than have an infusion for three months, you've got this super high level of iron, and then it will just gradually go lower, lower, lower. I would prefer someone not to have to be dependent on the iron infusions. Again, of course, they have a role, especially in a pregnancy, after pregnancy, of course. But we shouldn't rely on them as our kind of iron management if we haven't tried other options.
phoebe audio:you've spoken a few times about iron deficiency versus anemia. what's the difference and what does it mean to actually be anemic?
Izzy:anemic is when our hemoglobin is low. So the protein that travels in our blood and carries oxygen to our tissue. Anemia is when the hemoglobin drops. So, I think of iron deficiency in three phases. One, the slightly low ferritin. You might not have any symptoms. It's probably not impacting your performance that much. The second one is a theraton of, below 20, 15, you are going to feel tired. You will have, most likely have symptoms and that's why, just to go back to when I was in Nepal, I was so surprised. I was like, I feel great. I just climbed a mountain and it was really confusing. And then the third one is when you'll have anemia. So that's the kind of progression of iron deficiency. and you want to catch it in that first phase and work on nutrition, diet, maybe some supplements rather than becoming anemic feeling crap and having to get a couple of iron infusions.
phoebe audio:Oh, I see. That makes sense. Well, let's talk a little bit more about what it does feel like if you're iron deficient. I know before we started talking about some of the warning signs, but what the short and maybe long term impacts of having low iron or anemia?
Izzy:short term impacts, we think about the roles iron has in our body. So iron deficiency, important for energy production. not training as well, having less power, impacting your recovery, walk offs and colds. If you become, anemic, then you start to have Your heart rate might start to go high, you'll be like, wow, my heart's really beating or I'm feeling quite lightheaded and really a decreased ability to, decrease exercise tolerance. That would be the kind of spectrum that I would say from feeling a little bit tired. Maybe a bit poor recovery to oh my god, I'm going to pass out when I stand up. So it's a, big spectrum. In terms of long term impacts, I don't know if I could think of a specific long term impact from eye deficiency if it's treated. I can't imagine it's good for our body to have chronic anemia.
anna audio:Mm.
Izzy:But I would say in Australia that would be very rare for people who go to the doctors more than once every couple of years to get to the point of having You know, significant anemia from iron deficiency unless there was another cause such as bleeding from a bowel cancer or celiac disease. Some actual kind of medical condition that's know, causing such a big iron loss or inability to absorb it.
anna audio:And, you sort of touched on it before, in the like postpartum sense of increased injury, but just in general, can low iron contribute to overtraining
phoebe audio:syndrome or
anna audio:an increased injury risk?
Izzy:Overtraining syndrome is a fascinating Have you had anyone on your podcast syndrome? You should try and get a recovery expert because it's this very elusive State that we don't really have hard evidence on what is overtraining syndrome is it actually a clinical phenomenon?
anna audio:Mm.
Izzy:There's a lady called Shauna Halton I think who's like the recovery expert in Australia and she says she thinks she's only seen it a few times in her career but Can eye deficiency contribute to injuries? To be honest, I don't know the data, but from a common sense perspective. We know that, sleep deprivation increases injury risk. stress increases injury risk. I'm sure that iron deficiency, if you are not recovering, not training properly, you have high levels of inflammation in your body, that is not going to favor recovery or, injury prevention. I would have to look on the data. So I'm not going to pretend to know I know that specific answer, but maybe you guys can look up and see if there's any studies where it would definitely impact recovery. Okay. And if you're not recovered leading into your next session, you're more likely to get injured.
phoebe audio:Yeah. that makes sense. And yeah, we'll have to learn more about overtraining syndrome because that sounds like a very interesting area to dive into.
Izzy:I think recovery is a fascinating area of science in maybe noughties, there's been amazing sports science research on. training to get peak performance and I think a really big emerging field now is recovery because if you can get people to recover better they can train better and you know do more volume so it is a fascinating area which I think you know as athletes we love training but recovery that's not that exciting it's amazing like 15 minutes of foam rolling is so hard to achieve twice a week but seven hours of running no worries Um, but I think, yeah, getting a recovery expert could be, could be great. But we've talked a lot about the signs and symptoms of iron deficiency. I would say if you're an endurance athlete, you should just be having your iron checked every Six months. I think, I wouldn't wait until you're getting signs or symptoms. so many athletes have mild iron deficiency. Of course, if your ferritin was like 150, you don't need to get it in six months. I hardly ever have menstruating females with a ferritin greater than 100. So I think it's not a bad idea vitamin D is so important for athletes. We know low vitamin D is associated with increased injury risk, increased stress fractures, immune impacts. incredible studies done in college athletes in America on vitamin D. So, there's enough things that endurance athletes are prone to because of the crazy things they do, to suggest that they, should have, bloods probably done at least every 6 to 12 months.
phoebe audio:Yeah. Yeah. It's a good tip to just get it checked regularly because I feel like it's easy to just get used to how you feel
Izzy:Exactly, exactly.
phoebe audio:Yeah.
Izzy:And, you know, there's everyone who's, we all have a friend who goes, oh my goodness. I didn't realize I was that iron deficient and I got an infusion and I feel amazing. My Parkrun PB's come down 20 seconds. So it is really hard to notice a change and that's why I can talk about these soft symptoms but everyone is a bit different and maybe some people's iron deficiency presents with short tolerance and they feel moody because their body's just under performing. So you know, you should get it checked before you get into that point of symptoms.
anna audio:Yeah. It's tricky. Right? Like people who are running heaps, of course they're going to be so tired because they're running heaps. It's so hard to distinguish between that and, Oh, maybe I, something else is
Izzy:10 million percent and I talk to patients all the time because we have this new phenomenon of amateur athletes almost training like elite athletes, but they also have full time jobs and they have kids. And then they're wondering, why am I so
anna audio:A podcast.
phoebe audio:A
Izzy:And I, and A podcast, and I tell them, I go, you know, elite athletes nap in the day and they have someone telling them how much to eat and they have masseuses and they're training, they're running 160 Ks a week, but you're running 110 Ks a week. You are very much nearly training like an elite athlete and wondering why you're fatigued when you're trying to do all these other things as well. So yeah. get your bloods done because especially for women so often, especially for mums They end up taking on, caring, nurturing roles, doing all these extra bits for family You deserve to have your bloods test once every six months if you're running, all that time per week.
phoebe audio:I feel like, Izzy, there'll be so many people listening being like, I needed to hear that.
Izzy:Good, good
anna audio:deserve to have a blood test, treat
Izzy:Yeah, exactly. The healthcare system is there for a reason and oh my god, they waste a lot of money on rubbish. I've been in the public healthcare system. So, if, we can keep someone in hospital for 10 days because there's no, you know, theatre space for their knee surgery, you can get a five minute blood test.
phoebe audio:Yes.
Izzy:No.
phoebe audio:Um. all right. We, we're going to ask as a kind of final question, and we may, we may have covered all this already, but would you say there are any like major myths or misconceptions about iron, or running that need to be debunked?
anna audio:Hmm.
Izzy:and bias as a vegetarian, I would say, the thing that all vegetarian athletes get iron deficient and meat eaters don't is not true because I have heaps of meat eaters that are deficient and lots of vegetarians that aren't. Of course, you'll be more prone, but you can get iron from a non. sources and be sufficient. You might just need to put a little bit more effort into it. the next one, maybe saying that there's something wrong with you for getting iron deficient. It is not normal to be running 10 hours a week. okay. So the fact that you might be getting iron deficiency, also regular periods, a complete new phenomenon. In the past, we were either pregnant or breastfeeding from when we were 18 until our reproductive years ended. So.
phoebe audio:God.
Izzy:Losing blood every month is a pretty new phenomenon for civilization and that's another reason why people are becoming more iron deficient.
anna audio:Yeah.
phoebe audio:Love it.
Izzy:I guess if we could summarize it in I don't know, a few things that would be, one, get your iron levels checked rather than wait until you have symptoms, two, aim for a ferritin more than 50. We have good evidence to say that will improve your performance. Three, look at your diet and actually try and put a bit of focused effort into iron rich foods, pairing them with vitamin C. and just mainly eat enough because no endurance athletes eat enough. So that would be my main, if I could summarize the podcast in three things, that would be it.
phoebe audio:is perfect. Well yeah, watch, hopefully, 10, 000 girls Monday afternoon, booking in for a blood test to get their iron checked.
Izzy:And everyone knowing on their trivia question that 26 on the periodic table. I'm very glad I learned that for the podcast. Anyway, thanks so much guys.
anna audio:Thank you so much, Izzy, for coming on. We have loved this chat. I feel better educated about the old iron.
phoebe audio:Yeah. That was, that was such an interesting conversation. Thank you
Izzy:No worries,
phoebe audio:Izzy. Bye.
Phoebe:All right, so we're getting into the segment that is called the moment we've all been waiting for. Wow, it's a new segment. For today. Laptop's down. Laptop's down. So, talk us through. We spoke to Izzy late last week as you touched on the iron levels in the ep, and I believe the next day you went and got your iron levels checked. I actually think it might have been that afternoon. It was that afternoon? Yeah, well because I had a, what's it called, not a script to get one, like a, oh, like a blood test, a request one. Yeah, yeah, I had one that I'd gotten earlier and I just hadn't fulfilled yet. I hadn't actually gone and got the blood test. but when we chatted to Izzy, one of the things that she said which just completely blew my mind was Things can inflate, artificially, like inflate your iron levels or your ferritin levels on your blood tests. For example, if you've been running or if you've eaten or if you're sick. And I thought back to the last time I got a blood test, which was It was in the lead up to Berlin Marathon. I remember it was before I went overseas and when I was feeling really rubbish. And my blood test came back, on the low side. I think it was around 30, but it wasn't really bad enough to explain anything. But I just had this thought of oh, well, maybe it was just, well, A, now we know it should have been 50. 50 should be the goal. And B, I thought maybe that was actually higher than It should have been, and maybe I should have not run beforehand because I was sick when I got it and I'd just been for a run and had a big breakfast. Yeah, I think that probably sounds about right if I was feeling sick and tired. And so I, yeah. that afternoon I, cause I hadn't been for a run that morning. And so I was like, okay, this is actually the perfect time. I'll go along and get tested. And so I did. And then I got a message from my GP saying, your irons come back and I sent a screenshot to you cause I was like, well, yeah, well, and I gasped. And, well, Lidl. I don't even know why because funny. It kind of was funny though. It was a little bit funny. It was. I mean, you could explain so much. Yeah. Anyway, so your Ferris and Lidl was, Drumroll. That was a tap. My ferritin level was five. Although I don't want to make it sound like that's an, I feel like the drum roll makes it sound like that's an achievement. That's obviously a really bad thing. It was only, we're laughing because, because we love to laugh. And if you don't laugh, you'll cry. It's kind of funny that after a year of being like, why do I feel so exhausted? It's like the most obvious answer, like pretty much most girls who run, I'm iron deficient. I'm a woman, I'm vegetarian. Exactly. Um, but the other thing was that my hemoglobin was quite low. So that's when it goes from being iron deficient to anemic. So I went and saw the doctor and she was just like, yeah, I don't. You would be feeling exhausted right now. It's very validating. and Yeah, I imagine it would be, because, I mean, it's pretty amazing that you've still been able to run as much as Yeah, I guess so. I mean, I have been running a lot less over the last six months or so. Because I have just been feeling I'm not up to running as much as I normally. So, and that kind of makes sense. I think the thing that mostly makes sense is illness stuff, like how sick I was last year, and having low iron massively impacts your immune system. although, you know what I have to be careful of? I feel like I've caught myself a few times thinking that I don't need to now change my other lifestyle. just being like, Oh, that's the answer. It's because my iron, it's not because I wasn't sleeping enough and it's not because I wasn't, whereas obviously those things are going to have just as much of an impact as the iron. So I need to not get too complacent. Yeah, pretty, or just more like, literally the other night I was trying to figure out what time I was going to sleep and I was like, Oh, I need to go to bed early, cause I'm trying to hit seven hours a night. And then I said, Oh no, it's iron that was the problem. And I'm like, well, no, you still need to try and get seven hours a night. But yeah. So off the back of that, I got an iron infusion, which I got this afternoon, which is very exciting. so hopefully in the next couple of weeks, I'm going to start feeling a little bit better. Apparently it takes a couple of weeks. You've had a few before, haven't you? Yeah, I think I've had five or six. Yeah. In the celiac that I am. Yeah. I actually have found sometimes when I've been really bad, it's like being within a couple of days, I feel a little better. Wow. I'm so excited. I'm like, I feel a little bit, I feel a little bit sad in a sense that I have almost been pushing my body when it's been so low. Like it just hasn't been able to do what it, especially with something like running. And like Izzy said with endurance sports, you just need iron and I'm trying to do a marathon on like push my body and no wonder it's being like, no, I can't do it. not ideal, but good to know now. And what's the plan? Are you going to get your iron levels checked again in a couple of weeks? Yeah, so I'm going to get my iron checked again in three months. And in the meantime, I'm doing some other tests. a bit gross, colonoscopy and gastroscopy. Yeah, nothing gross about that. Um, just that, that's it. You know what we call it, we call it top and tail. Top and tail, is that right? In the celiac world. Had a few of those in your time as well, I hear. Um, well just because it's good to check, I mean, as we say, not eating meat, running, a lot of these things are indicative of, you know, or would predict that I'd have low, low iron. At the same time, I have been having supplements for the past six weeks or so. So the doctor was like, we wouldn't expect it to maybe still be this low. So good to, they do little checks basically just to make sure you're not getting any internal bleeding. But I'm sure it won't be. And then, I don't know, honestly, I'm gonna have to I'm going to meet with, Jess Rothwell, our favourite dietitian, and get some advice on how I could better incorporate iron into my diet. But I am considering eating some meat again. Eating some red meat specifically Because I think if the fact is if I'm not absorbing it that well through iron supplements and to be honest I iron supplements are really don't sit. Well, I have not found a way to take them. That's it. Oh my god Yeah Like some people just have figured it out and can take them But I just have not been able to find a way and I don't want to go through life feeling Blood and pain and having gut issues if I don't have to. So yeah, I'll definitely consider having some red meat. if that's what it's going to take to keep my iron levels. Where they need to be. And let this be a lesson to all of you running girls out there, to go and get your iron checked. Get it checked. Yeah, I can't wait, like, even this time next week when we record again. I wonder if I will start to feel it. Yeah, we can have a little segment over the next couple of weeks. Check in. Progress report. I actually am really interested, especially now because I've got the data through, my Aura Ring and my Garmin. I'm very interested to see, Do my data points start changing around like my heart rate and my sleep? Apparently sleep can be really impacted by iron. How quickly you recover in your sleep. Lots of things. Very interesting. Well, watch this space. Yes. Very exciting. this week's episode, we would like chat about something that's happening in Sydney in the next few weeks. Yeah, which, we've sort of been drip feeding, I feel, over the last couple weeks here and there, but we can officially announce it now, I think. Yeah, so in the spirit of Cheeky and celebrating International Women's Day, we thought we would go to Sydney. Yes. It will run the weekend of the 7th and 8th of March. Yeah, well overdue. Our Sydney debut, would you say? I know! So please, come Please come. or tell your friends, we would love to see you, and yeah, we're super excited. The details and the event page are to come in the following much like our Melbourne event, it will be sponsored by Nike and Ultraviolet, so you can pretty much guarantee that it'll be a good time. I am so excited, and we can't wait to see you all there. Can't wait! Thanks once again for listening in to Cheeky. Please, actually, I have a request. Okay. If anyone hasn't, are you able to please, wherever you listen to your podcast, go and give us a rating. So you can see that you can give up to five stars. Yeah. Please give us a rating, because that really helps with the pod. Whichever you feel best represents performance. But give it, yeah, give your honest, honest rating. Yeah. A five. Give us fives. No, I think we had a goal this year of having tighter, um, outros. We've gotta, we've gotta script them. Next week maybe we script our outros. Just, it's out of control. Alright,
Izzy:Woof! Oh, sorry about my naughty dog. Arnold, shush!
phoebe audio:Oh! Our listeners are used to naughty
anna audio:They are very used to naughty dogs, often masticating in the background.