Category Archives: iron deficiency

Still (Mostly) Alive

It’s hard to believe that only 11 weeks have passed since starting Intern Year and in the same breath, 11 weeks has flown by. I am almost done with my first rotation of this year (Acute Care Surgery) and with it, done with the bulk of my training for RDC! As expected, my running has had to take a bit of a back seat to everything else but I’ve done a reasonable job of continuing to train and build and finally have some long term goals in mind!

July: My only real goal for July was to survive and figure out what my running schedule might look like when the reality of 80+ hours of work hit. We had a relatively mild summer here and since I ran in the early morning for most of it, I really didn’t struggle too much with heat and humidity. I ran a very reasonable 181 miles and my long runs progressed to 16 miles. Workouts were non-specific (long trail runs, fartleks and easy tempos) and focused on general fitness acquisition.

August: I started to figure out what work was all about and finally managed to get through my days more efficiently. I hit the wall a bit energy wise in the middle of the month and finished up with only 165 miles. I did, however, get my first 20 miler in for the cycle and my workouts started to get more specific. I also started going to Orange Theory, which has been very interesting in terms of my perception of effort versus my heart rate.

September: After a relatively disappointing August, I have been trying to refocus more on my running in September. I am about as fatigued as I’ve ever been right now and my body is showing it with lots of general aches and leg heaviness. I did get another 20 miler in and my workouts have become even more focused (more on this later). I restarted my iron to make sure I’m tuned up from that perspective and have been focusing on sleep and stretching as much as I can to combat 80+ hours of standing/interrupted sleep/weird positions in the OR. I’m doing a check in half marathon in Johnson City this weekend and interested to see where I’m at as compared to both Unplugged and the Asheville Half. I don’t know what the topography of the course will be and the weather looks hot but it will be nice to have a supported “up-effort.”

I realized in August is that I have to become more flexible with training and with that, workouts have to become more intentional. I don’t have the recovery ability to do multiple workouts a week and instead, have to make do with a couple of quality efforts each week. Because of this and because I have been so frustrated with my stagnation, I finally decided to hire/bring on a coach. I say ‘bring on’ because I am working with Dave Ames, who is a friend beyond being a coach, and the decision was about as collaborative as it gets. As many people know, Will has been my coach forever but with intern year for him and an intentional shift in our marriage to be as focused on just being married and not being co-workers, co-coaches, athlete-coaches, it was time to make a different plan.

One of the amazing things about having a coach is that all I have to do is workout. One of the terrifying things about having a coach ARE those workouts. For example, I had a medium long run on Sunday with a workout built in that didn’t seem that difficult on paper but was EXTREMELY difficult. Similarly, I have a mile repeat workout today that I am convinced is all but impossible so I have the difficult task of convincing myself first that I can do it and second, getting through it. Dave gets incredible results from his athletes and furthermore, has a lot of experience with the sports psychology aspect of racing which I need almost as much as the physiologic piece.

My race schedule has evolved as well, with a new focus on the US 50K Road Championships (hoping to podium) in March and CIM 2018 for my (hopeful) OTQ attempt. This takes a little pressure off RDC where my main goal is to just get back into marathon running and hopefully undo some of the emotional baggage I am (still) carrying from Philly.

But first, the Bluegrass Half in Johnson City on Sunday!

Weeks in Review: 2/13/17 to 2/26/17

There’s no filter to undo those circles…

2/13/17 to 2/19/17

Monday: Early morning snowshoe run for 45 minutes because the snow was just too amazing to not play in. Plus, I’m signed up for the Northeast Snowshoe Championships so I figured I’d better get out and practice!

Tuesday: 8 miles with 4 miles at tempo pace. Downhill skiing in the afternoon.

Wednesday: 4.28 mile recovery run.

Thursday: 8 miles with 4.5 miles at steady state on the treadmill.

Friday: 3.25 miles easy.

Saturday: 45 minute snowshoe run at my parents. SO hard in all the snow.

Sunday: Off day.

Total Miles: 23.5 plus 90 minutes of snowshoe running.

2/20/17 to 2/26/17

Monday: 8 miles with 5 by 2 at interval pace followed by a mile at steady state.

Tuesday: 5 mile recovery run

Wednesday: 6.65 mile regular run

Thursday: 5 mile progression run

Friday: 10 miles of classic skiing at the State Meet.

Saturday: Long call. Lots of hospital walking but no run. 300 abs routine before bed.

Sunday: 11.3 mile long run.

Total Miles: 46.0

The last two weeks have been a bit of a whirlwind. When we’re on Inpatient Medicine, we typically work six days a week with one weekend day off. Since the State Meets fall on weekdays, however, I had to stack some weekends so that I could have the time off. This past week, my “off day” from the hospital was very much an on day at the rainy, windy classic State Meet. Needless to say, I’m pretty wiped out and amazed I ran at all!

The toughest girls you’ll ever meet.

And my resilient, wonderful boys relay team.

My workouts have felt pretty good lately, which I attribute in part to my being fastidious about taking my multivitamin with iron. I stopped taking extra iron after last summer because my running had decreased and the high sweat loss season was done. However, because of the size of my hematoma, I decided to add a multivitamin with iron back in and have felt much peppier on runs lately.

I finally feel like I’m getting in a rhythm with my early morning runs…which must mean it’s time to switch schedules again! I have one more week on Inpatient Medicine, then switch to Surgery Boot Camp. This has a later start time but I think I’ll continue to do my runs in the morning. As ski season winds down, I’ll also be looking to add Body Pump back in for strength training.

Week in Review 2.22.16 to 2.28.16

Monday: Tempo run. 15 minutes at T pace then 2 by 1 mile at M pace.

Tuesday: 4.5 mile trail run in Sunny Hollow.

Wednesday: 4 mile run on the treadmill.

Thursday: 6 mile run.

Friday: 5 mile workout with 10 by 1 minute hard, 1 minute easy. Felt really clunky at first but great by the end.

Saturday: 6 miles of skiing at Sleepy Hollow.

Sunday: 11.7 mile long run. Was somehow flying for this run, which is encouraging for Spring 2016!

Total Miles: 43.2

Better week! Happy to get two workouts in and even happier with the way my long run went today. It was windy and I worked all morning but I just clicked in and ran 7:30 pace that felt like jogging for almost 12 miles. I attribute some of this to my being excited to get an outdoor run in and some of it to switching up vitamins and learning to tolerate a bigger dose of iron. Regardless, it makes me excited for the season to come.

For this coming week, it’s States Week, so much of my energy will go to supporting the MMU team as they aim to win the championship on both sides. Running-wise, I’ll be doing a steady state run, another time based interval workout and a 1:40 long run. On my recovery days, I’m hoping to get back onto some trails but we have sketchy weather coming through that may make it too icy to be safe.

Improvement Season: Nutrition

Even though my season isn’t over yet, I had already begun to mentally transition to improvement season: the time of year when the snow flies and the roads get covered in ice and all you can do is hope to hang on to fitness til Spring. I like to use this time to build new habits or break bad ones so that when a training cycle starts, I just have to focus on the training.

My nutrition has never been a major concern but it’s never been a huge strength either. Although I like food, I’m not a foodie and tend to eat the same foods every day. I also have a couple of food allergies (peanuts and shellfish) that limit me. In the past few years, I’ve started to increase the amount of protein and fat that I eat and focused on quality of carbohydrates rather than quantity. This has helped me not be starving all the time

When I met with Kim Evans earlier this fall, we took a look at my diet based on a week of food logging and she concluded a few things.

  1. I wasn’t eating enough for my level of activity and the pattern of my eating left me in a catabolic (breakdown) predominant pattern rather than anabolic or balanced pattern.
  2. I was eating about 50% carbohydrates which is fine for a normal person, but relatively low for an endurance athlete
  3. My diet didn’t meet my needs for many of the major vitamins and minerals

Kim is an athlete too and was really good about recognizing that the middle of a training cycle isn’t the time to make huge changes to diet. I amped up my calories, tried to eat more carbohydrates and added in some power foods daily (sweet potatoes, mangos, dates and quinoa). Unfortunately, the additional carbohydrates didn’t sit well in my stomach so I had to hold on that after a few disastrous long runs with sprints to a porto-potty. I did go back to my old lunch plan of grain + protein + veggie, which worked out really well.

Now that I can tweak things, here’s my general eating plan for the coming months. It won’t be possible to eat my lunch bowls while I’m on surgery (it’s more grab what you can, when you can), but I am planning on Food Prep Sundays so that at least the rest of my meals can be good.

Breakfast: Coffee + creamer, Baked Oatmeal Protein Bar topped with Sunbutter, piece of fruit (I have been doing a cinnamon raisin bagel with Sunbutter but want more nutrition so am trying out baked oatmeal. Here’s the recipe I’m trying this week. The next improvement is to get rid of the fake creamer in my coffee. Gross, I know.)

Mid-Morning Snack: Almonds + dates + second coffee (Right now, I’m eating Toasted Coconut Almonds but would like to wean myself back to natural or at least just salted.)

Lunch: Grilled chicken sandwich + piece of fruit + Oats & Honey granola bar (Once Surgery is over, I’ll go back to my rice bowls).

Afternoon Snack: Pretzels + string cheese + guacamole (The 100 cal packs fit perfectly in my white coat pocket. I’m the human squirrel in the hospital, I swear).

Dinner: Big Bowl o’ Nutrition! Grain (quinoa, rice, farrow or sweet potato) + protein (tofu, steak, chicken or pork) + bag of steamed veggies (usually broccoli) + sauce (barbecue, teriyaki, buffalo, italian) Once Will is back from Norwalk and I’m done with Surgery, we’ll go back to making more diverse dinners together. I don’t mind eating the same thing every day, but he definitely does!

Supplements: Liquid Ferrous Gluconate (20 mL = 20 mg elemental iron), Women’s Gummi Multivitamin, Vitamin D, Fish Oil, Methyl Factors

What are your go-to meals? Have you worked with a sports dietitian before?

Week in Review 10.12.15 to 10.18.15

Ah, an adaptation week at last. Par for the course, I actually felt worse than I did during my full volume weeks but I know recovery is necessary.

Monday: 6 mile recovery run with Acadia while the girls did their workout. Acadia is running for Vassar so I was thrilled to get 45 minutes with her to hear all about college and her new team. Arms after my run.

Tuesday: 6.8 mile normal run.

Wednesday: 7 mile run, including a trial of my new Night Runner 270 shoe lights. I ordered these as part of a Kickstarter campaign and finally got to try them out. Full review coming soon but they were awesome!

Thursday: Tempo plus speed on the track. 5 by mile at tempo pace (5:57, 6:06, 6:12, 6:10, 6:13) followed by 4 by 400 at R pace. The 400s felt clunky at best but the miles were awesome. I definitely went too fast on the first one because I felt so good but was more honest about tempo effort for the other four. I was helped in this effort by the wind as it got pretty breezy on the track by the time we were done. 10 miles total. Legs after.

Friday: Off day, prorated at 6.8. I did jog around our home course for the race but kept it as minimal as I could. Amazing team day with every runner posting a season’s best and many posting huge lifetime bests.

We're so lucky to have a team parent who is a photographer! Me in my element.

We’re so lucky to have a team parent who is a photographer! Me in my element on Friday, watching my girls kill it.

Saturday: As Will said, it was like I had an oscillating fan on me on the track. Got a 4 by 1200 workout in between the snow squalls (yup!) and really battled the wind. The goal was 4:15 but I came through at 4:20 each time, which was a little over a second lost per lap. The Daniels SMART calculator estimated 32 seconds lost per mile given the wind speed so I’ll take it! 8 miles total with legs afterward.

Sunday: 13 mile long run with Will and Amy. Pretty chilly out and was actually really tired, so I was glad it was a short long run.

Total Miles: 58.2

As I wrote earlier in the week, I really am feeling better now after three weeks of liquid iron. Easy runs are back to normal and my workouts are happening at the paces I expect although I’m still really anxious every time I start one. My sleep hasn’t been great lately but I think that’s more to do with Will starting surgery and waking up at 5 am every day. I usually fall back to sleep but it feels more disrupted than normal.

The week ahead is back to normal volume (65 to 70) with a big marathon pace effort next weekend. We’re into Phase 4 now which means that after my regular workout efforts, I have to remind my legs how to be fast. Tough task as the weather gets colder and I’m at the peak of training!

Turning A Corner

When I first suspected I was anemic and then when I found out that I was, my biggest question was how long until I feel better?!? From talking with friends and former athletes who were anemic, it sounded like I should feel better quickly but I was skeptical and I couldn’t find any big research studies that quantified HOW much better I should feel.

The great news is that I feel SO much better and in even more exciting news, my paces are dropping with every workout. As I look back over my training log, the worst of my symptoms were during the beginning of September. On the 10th, I struggled through 800s, on the 15th through Ks and on the 17th I only did 2/3rds of a tempo workout because I felt so horrible. I started iron on September 24th and by the following week, I was already feeling better.

Here’s a couple examples of what three weeks of iron supplements have done in identical workouts:

  • 800s at I pace: in September, I struggled to hold 2:57 pace. Last week, with the remnants of a chest cold, I cruised at 2:49 pace.
  • 3 by 2 miles at T pace. In September, I didn’t even finish this workout but my first two pairs were 6:37, 6:44 and 6:42, 6:48. Last week, I finished the workout and my pairs were (6:22, 6:25) (6:15, 6:25) (6:21, 6:19).
  • Tempo Miles: The last time I did this workout, my tempo miles averaged 6:28 pace. This week, they were 6:08 pace.

Onward and upward!

Week in Review 10.5.15 to 10.11.15

Finally some hope!!!

Monday: 7 mile recovery run.

Tuesday: 3 by 2 miles at tempo pace. (6:22, 6:25) (6:15, 6:25) (6:21, 6:19). Much better than last time! 11.6 miles total.

Wednesday: 6 mile recovery run.

Thursday: 7 mile normal run.

Friday: 9 mile normal run. Put workout off because the weather was horrible.

Saturday: Intervals. 6 by 800. (2:50, 2:48, 2:48, 2:49, 2:48, 2:50). Hard to believe that a month ago, I was struggling through at 2:57 pace. 10 miles total.

Sunday: 18.2 mile long run in perfect fall weather.

Total Miles 68.8

Finally turning a corner! Between last week and this week, the tone in my running log has changed from “survived” to “felt great!” Easy runs no longer feel like slogging through quicksand and my workouts are both speeding up and feel much more reasonable effort wise, especially my tempo efforts. I’m a little over two weeks into my iron supplementation and feeling so much more like myself. I’m still adjusting my goals for Philly but with a whole lot more hope and happiness.

Week in Review: 9.28 to 10.4

Fall has arrived! From sweaty away in tank tops and short shorts to running in capris and long sleeves with gloves on in just a few days…

Monday: 7 mile recovery run with a few 400s in there as the girls did a workout. Tweaked my left glute doing RDLs of all things and was pretty sore for the rest of the week. Arms in the weight room.

Tuesday: Rainy 10.4 mile regular run with Erin and Megan. 6 by 100 meter striders.

Wednesday: Pouring rain and windy so had to get a bit creative with workouts. 3 mile continuous tempo on the track. 6:33, 6:16, 6:14 that felt easier and easier as the pace dropped. 11.75 miles total. Legs in the weight room.

Thursday: 5.1 mile recovery run. Beach abs with the team.

Friday: 10.4 mile interval workout that also had to be creative because the marching band was using the track (?!). 5 by 1000 on the roads around the high school, so pace was all over the place but all good effort.

Saturday: 7 miles while coaching around Thetford.

Sunday: 15.1 mile long run with Erin. Perfect fall day. Felt pretty clunky/tired but we got through it.

Total Miles: 67

Total Miles for September: 283 miles

Although workouts are still feeling pretty difficult, I’m starting to feel better on regular runs and am much less exhausted overall. The best example of this is that I managed to really lift this week rather than essentially collapsing after my runs. I’m getting used to being tied to my house three times a day for my iron but will admit that some days, I just end up doubling up my dose because I wasn’t home for one of them. I see Kim again this week and I’m excited/nervous to see what we come up with for tweaks. I do feel like my nutrition has been a little off track the last week or so because Will is back from Connecticut and I’m getting used to having someone else around for meals again rather than just eating on my schedule and my own meal preferences.

Now that I feel like my energy is coming back from its nadir, I’m starting to think about how I want to reframe my goals for Philadelphia. I don’t think a Trials Qualifier is a very likely outcome at this point but I’d still like to have a strong race and set myself up for the 2016 season. At the very least, I’d like to break 1:20. I’ll revisit in a couple weeks after I get some more workouts in but I think a reasonable A goal would be to break 1:18.

Depleted

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 (http://www.wholehealthnutritionvt.com/). 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!

Week in Review 9.21.15 to 9.27.15

Monday: 7.1 miles easy. Feeling pretty good post-race but sore in weird places. Lifted back in the gym.

Tuesday: 8 miles with the team on the Greenway in Cambridge. 3 at 7:25 pace for their tempo Tuesday.

Wednesday: 17 miles with 6 at MP. 6:52 away from the wind, 7:05 in the (crazy) wind. Actually felt pretty good. Legs in the gym.

Thursday: 5 mile recovery run. Started my iron supplement.

Friday: 8 miles by the ocean. Such a happy run.

Saturday am: 4 miles of coaching running; warmups, cooldowns only. Didn’t count my running around the course.

Saturday pm: 5 easy on 1A when I got back to the beach. Hip core.

Sunday: 10.3 mile interval workout. 16 by 400 but on the road so .25 miles. Pace was varied with wind and small hills but all between 83 and 89 with most 86 to 88. Actually felt pretty good. Legs after.

Total Miles: 65

All in all, not a bad week with two workouts that actually felt pretty good. I’m tolerating my iron well (more on that later) and I’m getting used to taking something three times a day while simultaneously promising to never prescribe something three times daily. The temperature change has been amazing and I’m actually looking forward to this coming week of running in short sleeves with minimal sweating!