Apologies for a super long post but as I’ve been struggling silently for a stretch of time, I was desperately searching for other runners with similar situations so figured I’d at least contribute to someone else’s search! Caveat: Although I give medical advice in my real life, I am not your doctor and nothing here should substitute for seeing your own doctor!! 

If you read my blog regularly, you know that I’ve been struggling for a few months with overwhelming fatigue and dead legs, leading to exponentially slowing workouts. At first, I assumed this was just a side effect of being a third year medical student. Then I attributed it to my sinus infection and ten day course of Augmentin. After the dust settled from that, however, and I still felt like I was trudging through quicksand and ending workouts on the track in tears, I realized I needed to call in reinforcements. Running isn’t always fun but I’m not someone who hates running or dreads workouts and when I do, I know something is up.

I don’t have any history of anemia nor do I have any major risk factors. I eat red meat (theoretically, it turns out I don’t really eat much of it), I cook in cast iron, I take a multivitamin with iron and I don’t have heavy periods. My only risk factors were high miles and the concurrent risk of foot strike hemolysis (banging your feet on the ground a lot kills off red blood cells) and serious insensible loss (sweating) from a hot summer. As a coach, however, iron deficiency anemia is an ever-present threat to team performance. After my own experience, I even sent apologies to the athletes that I’ve coached over the years who have been anemic because I totally didn’t understand what they were going through or how miserable they were.

I finally got into my doctor’s office last week and convinced them to check my iron levels. I wasn’t totally successful at this, but I did manage to get a ferritin and a hemoglobin/hematocrit done. If you’ve been through this as a runner, I’m sure you recall the struggle to get them to check iron in the first place. Many will just check a hemoglobin and hematocrit which is insufficient because you can have a perfectly normal H+H and still be well on your way to an iron deficiency anemia. Here’s how: ferritin is the storage form of iron and your body will do anything it can to keep your hemoglobin and hematocrit levels stable which includes drawing down your ferritin. If your ferritin is low but your H+H is normal and you don’t replace the stores of ferritin well, it’s only a matter of time til your other numbers drop. Bottom line: demand that your ferritin be checked!

They wouldn’t share my actual CBC values with me (clearly I need to switch offices) and made snarky comments about how I “know too much” but I did ultimately find out that my ferritin was 18. Not good. The table below outlines what we use when considering the various stages of iron deficiency.

From Uptodate

From Up To Date

As you can see, I fall in the category of iron deficiency without anemia. For a regular person, this might be tolerable. For an athlete who depends on her red blood cell mass for oxygen transport and her cytochromes for ATP generation, however, this can have enormous performance effects. At this point, the data on optimal ferritin levels for athletes remain mixed but 50 is almost universally accepted with a small group advocating for levels of 80.

In struggling through the past few weeks, I decided that in addition to figuring out my iron, I also felt that it had come time to see someone for sports nutrition. I eat a well-balanced diet and have a pretty high level of “food literacy” thanks to being raised by a Registered Dietitian but had to accept that if I managed to get iron deficient, I might not be as good at nutrition as I assumed I was. At the very least, I knew I needed some support in figuring out how I got to be so deficient and whether I had an absorption issue. My mom recommended a colleague in Burlington who specializes in sports nutrition and last Thursday, I had my first meeting with Kim ( To prepare, I had to keep a food diary and I was so unbelievably nervous about what she would say. What if I’d totally been fucking up nutrition for years and didn’t know it?! Was I eating too much? Too little? Needless to say, I had nothing to be nervous about and am really looking forward to working with Kim over the next few months. We’ll meet again next week but my homework for this week was to stop taking my multivitamin and get going on my new targeted supplements: iron, magnesium and methyl factors. I need to get some more blood tests to evaluate my full iron picture, Vitamin D, B vitamin and other cellular function tests, but Kim felt that because Philly is approaching rapidly, we needed to start supplementing for my most likely deficiencies. Ever the skeptic of any supplement, I ran these by my mom and she wholeheartedly agreed that these were all reasonable recommendations.

The process of repleting my iron is relatively simple; I’m taking Gaia liquid iron three times a day. Why liquid iron? I have an extremely sensitive stomach and when I’ve tried even vitamins with iron in the past, it’s resulted in me vomiting almost instantly. Ferrous gluconate is typically the easiest iron to tolerate and liquid iron is the easiest form of ferrous gluconate. So far, so good. It looks like motor oil and tastes like Jagermeister but it’s staying down.

The magnesium and methyl factors were new information to me, which is a perfect example of why you see someone who is an expert. Magnesium is a critical co-factor in the body and the symptoms of a deficiency are diverse including fatigue, nausea, vomiting, rapid heartbeat and muscle cramps and weakness. Causes of deficiency include chronic stress, poor diet, heavy exercise and use of antibiotics. I’ve started to take Natural Calm, a magnesium powder, every night. Not only does this give me my daily value of magnesium but it can help counteract the constipation associated with iron supplementation. There are multiple ways to take magnesium but a dissolved form is most easily absorbed. Finally, methyl factors refers to a super complicated cycle in the body that still makes me twitch from the medical boards. If you’re really interested, this paper is actually a great summary of methylation but suffice to say, if you can’t methylate (and a significant number of people are deficient in the gene) B12 and folate, your ability to convert certain amino acids into energy in the Krebs cycle is severely hindered. I’m trying these methyl factors once daily.

Now that a tiny bit of the puzzle is figured out, it’s time to replenish my body and aim forward towards Philly. I’ll keep updating here as I make changes with Kim and get further into my iron supplementation. Here’s hoping quicksand turns to firm ground again soon!

2 thoughts on “Depleted

  1. Brynne

    Very interesting. I went through all of the same steps as you (the fatigue, the blood tests – although I was allowed to see my results 🙂 – and now started supplements a few days ago). My ferritin was at 40, so not as bad. The doctor didn’t recommend anything but rest, but my chiropractor had me starting on iron, multivitamin, and the same Natural Calm magnesium. It’s nice to hear you’re getting the same recommendations, makes me hopeful it’s a good combo. I’ll cross my fingers for both of us!

    1. Runner Under Pressure Post author

      The irony is that I could see my results if I just open my chart but we’re not really supposed to look at our own charts. What flavor of the Natural Calm have you ended up with? I tried original and almost spat it out but really enjoy the raspberry lemon. Hope you’re feeling better soon!


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