Iron Supplementation Protocol

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  • #34758
    Elliot Singer

    I am a 17 yr old female runner, and I just found out I have low iron levels (ferritin is 14 ng/mL). I am going to supplement with Floradix Liquid Iron, but I have been getting mixed messaging in my research about the best protocols around taking it. Should a vitamin C supplement definitely be taken alongside it? Should it be taken on an empty stomach, before bed, before/after mealtimes? The dose is 10mL/2x day. I chose the supplement brand because it (apparently) causes fewer GI issues and absorbs more quickly. Any wisdom would be much appreciated, as I am trying to reverse the low-iron issue as quickly as possible.

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    Anonymous on #34830


    Thanks for writing in about your ferritin problem. Your right to be taking action as 14 is quite low. In my experience anything under 30 and the athlete will suffer severe performance degradation and fatigue. Under 50 is where we begin to see the first symptoms of fatigue and poor recovery with some performance drop off.

    I’ve had a fair bit of experience coaching young women and many have had low ferritin. Ferritin is slow to respond to iron supplementation. Finding the right iron supplement and dose can take time. Iron is normally bound to another element(s) and ferris sulfate is the most common to find in drug stores. It’s the cheapest and, from my experience the least bio-available and the hardest on your gut. It causes constipation in everyone I know of who’ve used it. Ferris Gluconate on the other hand seems to be much easier on the gut and more bio-available. It is harder to find though. Shopping on line will make the process easier.

    Heme iron, the iron that is the hemoglobin protein in animal muscle is the most absorbable/bio-available type of iron supplement. This is where the old axiom of eating red meat to cure anemia comes from. IT WORKS.

    Heme-iron supplements are available and I think they work the best of anything I’ve seen used other than chelated iron which is also more easily absorbed.

    As for dosage: Normal it is recommend to take more until you get adverse reactions like constipation or upset stomach. Here’s the rub: Having too much iron floating around in your blood (not bound to ferritin) can be a bad thing. Iron toxicity is dangerous and ironically the symptoms of iron toxicity are the same as those found when you have low iron, low ferritin levels. That is; fatigue, low energy and lowered work capacity. I always suggest that athletes get a full iron panel done along with their ferritin tests. I’ve usually seen the use of 15-20mg/day of elemental iron. Read the label to see how much elemental iron is in the supplement

    Low ferritin with high iron levels indicates that your body is not making more ferritin in response to the increase in iron. I suggest monitoring all these levels throughout your recovery. Continued dosing with iron supplements, in this case, can lead to iron toxicity. There can be other underlying medical contributing factors that need more workup.

    I’ve never personally used IV iron but have heard of some athletes who did use it and got very quick results in returning to health. Obviously you will need to consult your doc about this.

    I hope this info helps. Good luck.


    Elliot Singer on #34831

    Thanks so much for the feedback. I should’ve mentioned that I am vegetarian (I do eat fish though) for environmental reasons, which has probably been a factor in the low iron issue. The iron I am currently taking is liquid ferris gluconate, but I came across a brand that offers “36 mg of elemental iron per capsule‚ plus the active forms of folate and vitamins B6 and B12.” Would you suggest that over the gluconate? I think my main hesitation is with trusting unknown brands, as I know supplements tend not to be FDA approved and can sometimes be not entirely reliable. Are there any brands you would recommend? Additionally, for the full iron panel you suggested— with my original test I got a blood count which was in a normal range— not sure if that is significant?

    Anonymous on #34892


    I do not have any specific brand I can recommend over any other. I just do not have enough knowledge about this to speak with any authority. I understand your concerns about maybe getting lower quality supplements and I just don’t know what to tell you.

    I will tell you that I have seen this issue MUCH more frequently with vegetarians than with those that eat red meat. For about 15 years I coached junior XC skiers (mostly girls around your age) and typically had 1-2 vegetarian girls each year that struggled with low ferritin. It’s just a reality that we are evolutionarily adapted to absorb natural source Heme-iron better than these artificial iron salts that come in tables and liquids. If you want to stick with your vegetarian diet (fish does not contain heme-iron) you might consider getting some heme-iron supplement.

    A Cautionary Tale: In the early 1980’s I switched to a vegetarian diet when I was ski racing and training a high volume with lots of intensity. At the most important time for me, leading into Olympic trials in 1987, I became extremely fatigued. Training had notched to a higher level and I was not responding. I was a wreck. I got tired climbing a flight os stairs and would have stop and catch my breath and let my legs recover. Maybe these symptoms are familiar to you? I’d never heard of ferritin but luckily for me a doctor who worked with the US SKi Team had and got me tested. My ferritin was 9. He asked me if I was vegetarian. When I said yes he told me to go have a steak dinner. I did just that. I never took an iron supplement but with in a month or 2 (I can’t recall the exact time. It was a long time ago) of starting to eat meat my ferritin was up in the 30s and I felt so much better. It continued to improve for months and I managed to salvage the tail end of my ski racing season.

    This is only my personal experience but I’ve had a fair bit of experience.

    Good luck and get some heme-iron at the very least.


    Coach on #35011

    Hi Elliot,

    I am one of the XC skiers Scott mentioned above who he coached through low ferritin. It is a very frustrating process that takes time and it took me months to find the right supplement that worked for me. I suggest trying other things until you find one that works well. I found a great supplement that I will link below called Thorne Ferrasorb. I am not sure if it is FDA approved but it was recommend to by a nurse and I have been using it for years now with great results. It took me about 4 months to figure out a supplement that worked well, that didn’t give me stomach ache and actually was absorbable by my body. The great thing about this specific one is it has Vitamin C, B6 and B12 all in the capsule. All three of these vitamins are crucial to iron absorption as you have probably already read. I still take it with food or else I do get a bit of a stomach ache but nothing too serious compared to other things I have tried. I did liquid iron for a while but it ended up getting iron toxicity so be careful with that type of supplement. If your ferittin doesn’t improve after a couple months I would recommend being tested for Vitamin B12 mutations. It turned out I don’t absorb most types of vitamin B which was preventing Ferittin build up. This pill however does have the specific B12 my body can absorb which is another reason I like it.

    This can be a long process but don’t give up! You will feel so much better once you find the right supplement that works for you! I hope this is helpful and good luck!

    Rebecca Dent on #35697

    Hi Elliot,

    Just some practical nutrition guidance for you on your low iron.

    Firstly who carried out your blood test? If it was your doctor I would hope he/she would have advised accordingly on dose and duration of iron supplement. It can take up to 3-6months to restore low iron levels (iron deficiency) or anaemia (usually classified as levels lower than 12 so you are right on the cusp) via supplementation.

    As Scott explains I would like an individual endurance athlete particularly female to have serum ferritin levels above 50 to ensure optimal performance and health. I would carry out a full assessment history as to why your levels may have dropped (e.g. vegetarian diet as you follow so lower intake of animal based iron (the haem iron Scott refers to), menstural losses/blood flow, training at altitude, endurance training all of which increase requirements for iron intake or cause an increase in usage of iron). In order to then put in strategies to prevent them from dropping again.

    When taking an iron supplement it is important to:

    1) Take it with a source of vitamin C such as a glass of fruit juice which aids the absorption or iron.

    2) Avoid drinking any caffeine substance 60mins around taking the supplement as caffeine inhibits the absorption of iron.

    3) It is also important to increase your intake of iron rich containing foods, as ideally you do not want to stay on the supplement long term but to support iron levels via dietary intake.

    4) As a vegetarian and young female endurance athlete your daily iron requirements are increased so it is about planning a more considered dietary intake to include iron rich plant based foods daily.

    5) It is about finding one that does not upset your stomach.

    I would caution against an IV infusion especially if you are competing nationally or internationally as it is prohibited by the world anti doping agency (WADA).

    Elliot if you want to sign up to a phone consult we can chat this through in detail and I can give you more support. It’s important you get this right both short term and in the long term and get individual guidance for you.

    Hope that helps.

    Rebecca Uphill Athlete Dietitian

    pshyvers on #36316

    I learned recently that eating vitamin C at the same time as non-heme iron has been experimentally observed to nearly triple iron absorption. Note this was not throughout the day but in the same meal. Since then, have been working to include fresh fruits, berries, citrus in meals with plant sources of iron. Note that while onion contains vitamin C, the vitamin is fragile & destroyed with heat.

    Christie on #36322

    Hi Elliot

    I’m a human who is an athlete, nurse practitioner, and also experienced very low ferritin levels. I agree to the great (evidence based) information has been provided above.

    I have received IV iron (common therapy in Canada if your levels are so low). It was amazing, and I can actually enjoy going up hill now. Yes, it is prohibited by the world anti doping agency (WADA).

    Couple of Tips:
    -I added list of foods contain high iron/vitamin c on my phone as reminder (grocery shopping), found the visual cues helpful.
    -The “Lucky Iron Fish” is a simple and effective cooking tool that adds extra iron to your daily foods or drinks. It was develop by a colleague of mine, initially as creative way to treat iron def. anemia in Cambodia. Iron deficiency negatively impacts over 2 billion people on the planet. Yikes!
    -Since it can take 3-6 months (or longer) Floradix Liquid Iron 6x500mL bottles cost $239 (Canadian), ferrous gluconate tablets likely more cost saving (1 bottle per month (at max dose 100mg/day) cost $4.74 cdn).
    -Liquid forms of iron tend to stain your teeth.

    -if the iron upsets your stomach;
    -you can try taking it a bedtime.
    -take iron supplements with meals (iron absorption is enhanced when supplements are taken on an empty stomach; however, tolerance and adherence may be improved when iron is taken with meals)
    -iron supplements can be taken every other day.

    -I wouldn’t personally train at high altitude with ferritin levels below 50 (I imagine it would feel very terrible and my suggestion is based on former high altitude training protocol-best to ask Scott).
    -adequate ferritin levels is also helpful to support your immune function, which I think is very important to endurance athletes.

    I hope this is helpful

    uphill_dhamma on #36680

    Hi everybody and thanks for all these messages about this topic.
    I’m following this because (long story short): I’ve been struggling with low ferritin levels since 2-3 years now.
    And (I know, that’s crazy) even without solving it I did 2 intense ultra trail seasons (= years) probably pushing my body beyond its limits.
    Result = after my best season I probably ended up overtrained and still with low ferritin / iron levels whenever I introduced some volume/intensity.
    I’ve been (and currently are) under doctor / specialists control but they never really solved this issue.
    I still keep having ferritin levels in the 8-12 ng/mL range.
    This even if I take iron supplements.

    Diana on #36688

    This isn’t a full fledged solution by any means, but I like to eat oysters for iron. Mollusks have much more iron than fish, and oysters are quite sustainable as far as seafood goes. Smoked oysters in a can are super convenient and delicious on crackers after a workout! 🙂

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