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I have struggled with iron deficiency and anemia basically since I started running. I have always been a healthy eater eating lots of fruits and vegetables and anything else I was offered; I have never been picky either. I remember going for a physical as a young kid, probably my fifth grade physical, and being slightly anemic. My sister on the other hand, whose answer to the doctor's question of, "Do you eat vegetables?" was, "Yes, raisins," had perfect lab results. It seemed ironic to me the kid who ate exactly what she was supposed to was anemic, and the chicken fingers and French fries feen got a clean bill of health.

As I became more competitive in high school, I started to feel the effects of low iron counts. I couldn't finish quarter workouts and watched over 90 other runners pass me at the 1/2 mile to go of the conference race despite my fitness levels. In college I was frustrated to find that I was still anemic despite eating the prescribed red meat and taking iron supplements. I just crossed the non-anemic barrier only by consuming two pills daily. Just last summer I was feeling light-headed often, and once again, lo and behold, pronounced slightly anemic!

The happy ending to this story is that I haven't been anemic since. Soon there after, I chose to venture into the wheat-free zone. After spending many nights doubled over in pain or in the bathroom with gastrointestinal discomfort to say the least, I thought it was worth a try. After one week of avoiding my standard cereal, sandwich, pasta diet, I was symptom free. And one year later, my hematocrit is "like a man's," according to my doctor. Simply by eliminating wheat from my diet, I improved the absorption of the iron. I apparently have had a wheat sensitivity for years, contributing to my chronic anemia.

I do not have Celiac and I really am not allergic to wheat. It is more of an intolerance, or a sensitivity. Whenever I eat wheat, antibodies are released to protect against the foreign invader, wheat. A chain inflammatory reaction occurs, causing absorbance to be sacrificed and my gut to be swollen. When nutrients are not absorbed properly, vitamin and mineral deficiencies result, hence the anemia. If you have had multiple bouts of anemia and follow an iron-rich diet, consider your ability to absorb the nutrient. Look for common culprits in your diet - wheat, milk, and eggs as well as nuts, shellfish and fish, and other gluten containing grains are the most likely allergies and sensitivities to food. Other symptoms of food sensitivities may include skin problems (acne, eczema), poor immune system, chronic congestion or sinus infections, headaches or migraines, or frequent cravings or mood swings.

The Science Behind It

The hemoglobin within a red blood cell is responsible for carrying iron. Oxygen then attaches to the iron. Anemia can result from insufficient RBCs, not enough hemoglobin, or not enough iron. A hemoglobin molecule has four protein, or globulin, subunits, each with a heme group and iron atom in the center. The iron atom combines with oxygen molecules.

Oxygen binds to hemoglobin in a cooperative manner, meaning after one oxygen molecule binds, the structure changes shape, making it easier for other oxygen molecules to bind.

Fe3+ , or the ferric form of iron, cannot bind oxygen. It must first be oxidized, so it is best to take ferrous (Fe2+) form.

How much iron do we need? The Recommended Dietary Allowance (RDA) is 8 mg for adult males and 18 mg for adult females. Because of the higher levels of red blood cell destruction in runners, we can get away with supplementing with 100% of the RDA even without deficiency. Iron should be taken in the more absorbable ferrous state. There are three forms of supplemental iron - ferrous fumerate, ferrous sulfate, and ferrous gluconate. Ferrous fumerate has the highest percentage (33%) of elemental iron, meaning it is the best absorbed. Ferrous sulfate and ferrous gluconate have 20% and 12%, respectively.

If taking more than one pill to supplement, it is best to split up the pills - only a set amount of iron is absorbed at one time. When hemoglobin levels are below normal, physicians often measure serum ferritin, the storage form of iron as well.

Am I Anemic?

Anemia is defined as insufficient red blood cells (RBC) to carry oxygen to your tissues and brain. Anemia can be a result of disease or vitamin deficiency as well as blood loss. Besides needing iron to make red blood cells, the body must also have sufficient vitamin B12 and folate for RBC production. Females are more susceptible to an iron deficiency because of menstruation. Runners are at a greater risk for iron deficiency for many reasons.

Nutrient absorption in runners is impaired after long runs or intense workouts. With a strenuous effort, blood is predominantly flowing to the muscles, heart, lung, and brain. The gut is the bottom of the blood totem pole at this point. Unfortunately, this results in poor digestion and absorption of nutrients due to villus blunting. Villi in the small intestine are responsible for nutrient absorption. Blood flows to the top of each villus "mountain," but when the blood isn't flowing to the gut, the villus tip temporarily dies and cannot absorb nutrients. As blood returns to the villi, absorption is resumed, but in the meantime, malabsorption and diarrhea are common.

Runners also are at a higher risk of anemia as a result of iron lost through sweat and red blood cell destruction from mechanical trauma, ie the pounding of each foot strike. Training at altitude further puts an athlete at risk.

Mechanical trauma, also called foot strike hemolysis (hemo- meaning blood and -lysis meaning death of a cell) occurs from vascular and red blood cell trauma in the foot. Also, red blood cells are more prone to oxidative damage, naturally occurring during exercise, which will speed the destruction of the cells.

Pseudoanemia, common in athletes, is caused by an expansion in overall blood volume. This dilutes the red blood cells, causing a false representation of anemia in blood tests, but does not usually cause problems with athletic performance. Actually, the increased blood flow aids in oxygen delivery.

Symptoms of anemia or iron deficiency include fatigue, pale skin, shortness of breath, dizziness, cold hands and feet, and headache. These symptoms normally do not appear in pseudoanemia. It is important to still get a blood test (CBC or complete blood count) to confirm a deficiency because iron can be toxic and harmful to the liver if too much is stored. A blood test will look at the following markers and help determine the cause of anemia:

• Serum Ferritin - levels of stored iron, 18-270 mcg/L (m), 18-160 mcg/L (f)
  
• Total iron binding capacity - protein that carries iron in the blood, measures how much transferrin in the blood is not carrying iron, 20-50%
  
• Red blood cell (RBC) - total number of red blood cells in that sample of blood, 4.2 - 5.6 mill/mcl (m), 3.9 - 5.2 mill/mcl (f)
  
• Hemoglobin (Hb) - protein in red blood cells that carries oxygen, 14-18 g/dl (m), 12-16 g/dl (f)
  
• Mass Cell Volume (MCV) - average volume of a red blood cell, clue to the cause of the anemia because cells are small in iron deficiency anemia as compared to a B12 or folate deficiency (pernicous anemia), 80-100 fl
  
• Hematocrit (Ht) - proportion of red blood cells in overall blood, 42-54% (m), 38-46% (f)
  
• Mean corpuscular hemoglobin (MCH) - average hemoglobin in the average red cell, 27-33 pg
  
• Mean corpuscular hemoglobin concentration (MCHC) - average concentration of hemoglobin in a given volume of red cells, 32 - 36 %

Over the course of the next few days, I will further discuss iron deficiency and anemia. I will describe the red blood cell structure, ways to increase absorbency therefore preventing a deficiency, and my own personal experience with anemia. I look forward to questions and comments!