Feeling drained recently? Do you want to exercise but every time you lace up your shoes, do your legs seem like they have lead weights strapped onto them? Do you get out of breath more easily or seem to tire just thinking about walking?

Have you been to the doctor and explained about your unending fatigue?  Did your health care provider send you for a standard blood test and then tell you that everything was “normal” and tell you that you may just be depressed?

You’re not alone. Fatigue is one of the number one complaints heard by physicians from their patients, and often misdiagnosed or not investigated properly.  Yet, what if there was a reason for your fatigue and other symptoms, and your misery regarding exercise and getting moving had a real cause that wasn’t related to being depressed or getting older?

redbloodcells What if you had an iron deficiency that was never properly analyzed  by your doctor?

More often than not, unfortunately, physicians are taught only to recognize full blown anemia which shows up on a Complete Blood Count (CBC) blood test. In cases of full blown anemia levels of hemoglobin and hematocrit will show up as low or below the normal range.  Many physicians stop their investigation at this point, even if the patient asks about their iron level as a cause for the fatigue and symptoms they are having, and are mistakenly told by their physician that since their CBC was “normal” their iron was “fine’".

However, many sports medicine physicians and athletes have long recognized that a low ferritin level (which is a storage protein in the body which is responsible for storing iron), can negatively impact athletic performance.  And since low ferritin levels can impact athletes—low ferritin can also impact you.

  The best test for iron deficiency is not the hemoglobin and hematocrit, it’s the serum ferritin level.  Iron overload can also easily be identified by the presence of too much ferritin in the blood.

Furthermore, in 2003 the British Medical Journal published findings that patients who had normal hemoglobin and hematocrit, but low ferritin, had fatigue that was reversed by iron treatment.

Jill Waalen, MD, MPH, Research Associate, Vincent Felitti and Ernest Beutler, The Scripps Research Institute, La Jolla, California in the United States,  says that the issue of iron supplementation in treating fatigue in women who were not anemic has been a significant health problem for years.

Waalen says that patients with fatigue and other symptoms  have actually been shown to be helped by iron therapy even if they were not anemic for a period of more than 150 years. 

What your doctor may not know is that mild iron deficiency can occur and lead to low ferritin levels, before blood levels of the hemoglobin and hematocrit show abnormalities. And this lack of knowledge, can cause some patients to suffer needlessly with fatigue, headaches, and other symptoms of low iron, and often progress into full blown iron deficiency anemia, simply because their doctors never bothered to test their ferritin levels.  Early onset of iron deficiency anemia may be identified by a low ferritin count and is of critical importance to stop the progression of mild iron deficiency into moderate or severe iron deficiency anemia.

Symptoms of Low Ferritin:

Tachycardia (Elevated Heart Rate)
Heart Palpitations
Easily Exhausted after Exercise (Difficulty in Recovering after Exercise)
Brain Fog
Feeling Faint or Feeling Like You could Faint
Hair Loss
Pale Skin
Decreased or Loss of Libido
Easy Bruising
Brittle Nails
Cravings for Ice (Pagophagia)
Pica (craving and eating of non-food items)

Q: Why is Iron Important?
A: Iron is what binds to oxygen. And of course, we all need oxygen to carry oxygenated blood to our lungs and our working muscles.   Iron, however, is also crucial to the actual metabolism in our body. Iron and it’s deficiencies not only can play a part in making the body perform less efficiently with regards to work and exercise, but having too little iron stores can also decrease your ability to resist infection, and impact your ability to think clearly.

Q: But don’t we need just a little iron and don’t we all get enough from food?
A: Iron can be lost in various ways including through the gastrointestinal system as well as through sweating. Furthermore, some patients have difficulty absorbing iron, or conditions such as hypothyroidism which is also a red flag to check for low serum ferritin levels. 

Q: What About Low Ferritin Levels and Thyroid Disease? My doctor says she doesn’t need to test Ferritin because I’m not anemic?
A: Iron deficiencies may be even more important to address in patients with thyroid disease because iron deficiencies can affect thyroid metabolism and even further reduce the conversion of T4, the inactive hormone to the active T3. Moreover, iron deficiencies can modify the actual binding of the T3 hormone in the body.  Furthermore, TSH levels can be increased if iron deficiencies are not addressed by physicians treating thyroid patients. 

Q: What substances or foods inhibit iron from being absorbed?
A: Coffee, Tea, Calcium,  Non Steroidal Anti-Inflammatory Medications (NSAIDS) such as Advil or other types of Ibuprofen, Carbonated Beverages.

Q: How Else Can Iron Be Lost?
A: Menstruation can be a source of iron loss for women, as well as both male and female runners and athletes

Coaches of distance runners have said that low ferritin levels in runners who have had normal hemoglobin and hematocrit levels have experienced significant reductions in performance as well as distressing symptoms.  Inappropriate levels of exhaustion, increased numbers of injuries, heavy legs, decreased motivation, and muscle tightness.

Coach Jeff Hess, who coached multiple state champions in Oregon and an accomplished runner himself, says that overuse injuries from runners double with ferritin levels less than 20, and increase three fold in those runners with levels under 12.  Yet labs which can vary, may list “normal iron levels ranging from 10-300 ng/ml”.  

What many doctors are not addressing, are the cases where a patient may have normal levels of hemoglobin and hematocrit, but very low normal ferritin stores. Many experts are now saying that ferritin levels  less than a 60 ng/ml should be cause for treatment with iron supplementation.

Coach Hess has seen the consequences of low ferritin levels in female runners he coached. He says in 2001 three of the school’s female long distance runners had ferritin lab levels which showed up as 10ng/ml.  Each one of the girls had their most successful races and speeds two years prior,  but all three were experiencing injuries and aggravations with their current low ferritin levels.  Even throughout the two year period when all three girls were struggling, not one doctor checked their serum ferritin levels until the school tested the girls’ ferritin levels and at that point identified that each was very low.

Four weeks after the runners began iron supplementation, they all reported less fatigue and additional energy, and speeds for each girl increased.  At the two month mark the ferritin stores in the girls ranged from 35 – 55 ng/ml. And each one continued running on the college level, and increased their times over and above what they were doing in high school.

Let’s find out from some other experts what they think about iron and it’s importance. 

Pete Pfitzinger, M.S. Interviewed Dr. David Martin, Ph.D from the Cardiopulmonary Science Department at Georgia State University was asked what he thought about low ferritin levels and performance.

“Dr. Martin,  believes that ferritin reflects the iron stores that can be utilized to make enzymes for oxidative energy production, and therefore has a direct impact on performance. Dr. Martin says that in his experience with runners, training and racing performances are usually affected when ferritin levels drop below 20 ng/ml, and that when those athletes increase their ferritin levels above 25 ng/ml they experience a rapid turnaround in performance. “

Jill Whalen, MD MPH, believes that the answer may not be with regards to changing the reference ranges for serum ferritin, but more likely, to train physicians to recognize that iron deficiency can be problematic in patients who are not yet anemic.   Physicians, Whalen said should be encouraged to investigate iron deficiency levels in causes of “unexplained fatigue” in their patients.  Increasing doctor’s awareness of the importance of testing serum ferritin levels and further education of clinicians could lead to more physicians considering iron deficiency as a differential diagnosis of fatigue, especially in women patients whose serum ferritin levels were in the lower levels of the reference range, irrespective of their levels of hemoglobin.  

According to Dr. Whalen, “A trial of iron therapy for a limited period of time in these patients would provide the diagnosis as well as the cure, and seems quite free of risk.”

It is important to be properly tested for both ferritin and your serum levels of iron and  to discus your options with your doctor prior to beginning any iron supplementation or any other medication. 

If your doctor is not willing to test your ferritin levels, you may want to have a discussion with your doctor about the relationship of performance to low ferritin levels and ask them if they’d at least be wiling to test you. If they are not, it may be time to find another doctor, because iron in your body is important in so many ways. Having too much or too little iron is problematic, but getting the ferritin level stabilized can help get you your get and and go back.

Low Ferritin and Iron Deficiencies References:

1. A Coaches Perspective on Iron

2. Verdon F, Burnand B, Fallab Stubi C-L, Bonard C, Graff M, Michaud A, et al. Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomized placebo controlled trial. BMJ 2003;326:1124 -1130.

3. Beutler E, Larsh SE, Gurney CW. Iron therapy in chronically fatigued, nonanemic women: a double-blind study. Ann Intern Med 1960;52:378-394.

4. Beutler E. History of iron in medicine. Blood Cells Mol Dis 2002;29:297-308.

5. Friedmann B, Weller E, Mairbaurl H, Bartsch P. Effects of iron repletion on blood volume and performance capacity in young athletes. Med Sci Sports Exerc 2001;33:741-746.

6. Brutsaert TD, Hernandez-Cordero S, Rivera J, Viola T, Hughes G, Haas JD. Iron supplementation improves progressive fatigue resistance during dynamic knee extensor exercise in iron-depleted, nonanemic women. Am J Clin Nutr 2003;77:441-448.

7. Rushton DH, Dover R, Sainsbury AW, Norris MJ, Gilkes JJH, Ramsay ID. Why should women have lower reference limits for haemoglobin and ferritin concentrations than men? BMJ 322:1355-1357.

8. Waalen J, Felitti V, Beutler E. Haemoglobin and ferritin concentrations in men and women: cross sectional study. BMJ 2002;325:137.