If I could test one thing on every female runner who walks through my door, it's ferritin. Not "iron levels" — specifically ferritin, your iron storage tank.

Here's why: every time you lace up and run at 7,100 feet in Colorado Springs, your body is working overtime to make red blood cells. That takes iron. Every time you have your period, you lose iron. Every time your foot strikes pavement, you destroy a tiny number of red blood cells. Add those up over a season and you've got the #1 reason female distance runners feel "inexplicably tired" — and it has nothing to do with training load.

I've had athletes who were running 50 miles a week and training hard, but couldn't hit paces they'd run easily the prior season. Ferritin was the culprit every time. Get it tested. Don't wait until you're anemic to act.

---

Why Female Runners Are Vulnerable

Losses

• Menstrual blood loss (significant iron)
• Foot-strike hemolysis (red blood cell destruction)
• GI bleeding (minor)
• Sweat losses

Demands

• Training increases blood volume
• Muscle repair requires iron
• High mileage = higher needs

Intake

• Many female athletes under-eat
• Plant-based diets lower in absorbable iron
• Calcium interferes with absorption

---

Stages of Iron Deficiency

[!IMPORTANT]

Stage 1: Depleted Iron Stores

The storage tank (Ferritin) is draining, but Hemoglobin remains normal. You likely feel fine, making this the critical window for early dietary intervention.

[!IMPORTANT]

Stage 2: Iron Deficiency Without Anemia ("Pre-Anemia")

Ferritin is critically low, and Hemoglobin is now borderline. You will begin experiencing systemic fatigue, unexplained heavy legs, and declining performance despite training hard.

[!IMPORTANT]

Stage 3: Iron Deficiency Anemia

Both Hemoglobin and Ferritin have collapsed. Red blood cell production is compromised. Performance falls off a cliff, and you require immediate medical treatment (often infusions or heavy supplementation) to recover.

---

Symptoms of Iron Deficiency

Physical

• Fatigue (beyond normal training tiredness)
• Weakness
• Cold hands/feet
• Pale skin, especially nail beds
• Shortness of breath
• Increased heart rate

Performance

• Declining performance despite training
• Can't hit paces that used to be easy
• Poor recovery between workouts
• Hitting a wall in training

Other

• Brittle nails
• Hair loss
• Craving non-food items (pica)
• Frequent illness

---

Testing Recommendations

Key Tests

• Ferritin: Storage iron (most important marker)
• Hemoglobin: Part of complete blood count
• Serum iron: Circulating iron
• TIBC: Total iron-binding capacity

What to Ask For

"I'd like to have my iron levels checked, including ferritin."

Optimal Levels for Athletes

Test	Standard "Normal"	Athlete Optimal
Ferritin	12-150 ng/mL	35-50+ ng/mL
Hemoglobin	12-16 g/dL	13-14+ g/dL

Note: "Normal" doesn't mean optimal for performance.

When to Test

• Baseline at start of season
• If experiencing symptoms
• Every 3-6 months for high-risk athletes
• Before major training blocks

---

Dietary Iron Sources

Heme Iron (Well Absorbed)

Food	Iron	Notes
Beef (3oz)	2-3mg	Very well absorbed
Chicken thigh (3oz)	1mg	Dark meat better
Oysters (3oz)	8mg	Highest
Shrimp (3oz)	2mg	Good option

Non-Heme Iron (Less Absorbed, Still Important)

Food	Iron	Notes
Fortified cereals	18mg/serving	Check labels
Spinach (1 cup cooked)	6mg	Pair with vitamin C
Lentils (1 cup)	6mg	Good plant source
Beans (1 cup)	4mg	Versatile
Tofu (1/2 cup)	3mg	Firm tofu best

---

Optimizing Iron Absorption

Enhancers (Pair With Iron)

• Vitamin C (citrus, tomatoes, peppers)
• Meat eaten with plant iron
• Acidic foods

Inhibitors (Separate From Iron)

• Calcium supplements and dairy
• Coffee and tea
• Phytates (whole grains, legumes)
• Antacids

Practical Strategy

• Take iron supplements separately from calcium
• Wait 1-2 hours between iron and coffee/tea
• Add lemon/orange to iron-rich foods

---

Supplementation

When Supplements Are Needed

• Ferritin below 35 ng/mL
• Symptomatic iron deficiency
• Can't meet needs through food
• Under medical supervision

Types of Iron Supplements

Type	Absorption	GI Side Effects
Ferrous sulfate	Good	Higher
Ferrous gluconate	Moderate	Moderate
Ferrous bisglycinate	Good	Lower
Iron IV	Fastest	Medical setting

Dosing

• Typically 30-60mg elemental iron
• Every other day may be as effective as daily
• Takes 3-6 months to restore stores
• Retest after 3 months

Side Effects

• Constipation
• Nausea
• Dark stools (normal)
• Take with vitamin C, not with calcium/coffee

---

Prevention Strategies

Dietary

• Include heme iron regularly (red meat 2-3x/week)
• Fortified cereals
• Vitamin C with meals
• Avoid coffee/tea with iron-rich meals

Training

• Gradual mileage increases
• Prevent overtraining
• Adequate recovery

Monitoring

• Regular testing
• Know your baseline
• Track symptoms

---

Quick Reference

Warning Signs

• Unexplained fatigue
• Declining performance
• Unusually heavy periods
• Pale appearance

Key Actions

• Get ferritin tested (not just hemoglobin)
• Aim for ferritin 35-50+ ng/mL
• Include heme iron sources
• Pair iron with vitamin C
• Supplement if needed

---

Questions? Reach out at aspireperformancerd.com — I work with teams and individual athletes across Colorado.

If I could test one thing on every female runner who walks through my door, it's ferritin. Not "iron levels" — specifically ferritin, your iron storage tank.

Here's why: every time you lace up and run at 7,100 feet in Colorado Springs, your body is working overtime to make red blood cells. That takes iron. Every time you have your period, you lose iron. Every time your foot strikes pavement, you destroy a tiny number of red blood cells. Add those up over a season and you've got the #1 reason female distance runners feel "inexplicably tired" — and it has nothing to do with training load.

I've had athletes who were running 50 miles a week and training hard, but couldn't hit paces they'd run easily the prior season. Ferritin was the culprit every time. Get it tested. Don't wait until you're anemic to act.

---

Why Female Runners Are Vulnerable

Losses

• Menstrual blood loss (significant iron)
• Foot-strike hemolysis (red blood cell destruction)
• GI bleeding (minor)
• Sweat losses

Demands

• Training increases blood volume
• Muscle repair requires iron
• High mileage = higher needs

Intake

• Many female athletes under-eat
• Plant-based diets lower in absorbable iron
• Calcium interferes with absorption

---

Stages of Iron Deficiency

[!IMPORTANT]

Stage 1: Depleted Iron Stores

The storage tank (Ferritin) is draining, but Hemoglobin remains normal. You likely feel fine, making this the critical window for early dietary intervention.

[!IMPORTANT]

Stage 2: Iron Deficiency Without Anemia ("Pre-Anemia")

Ferritin is critically low, and Hemoglobin is now borderline. You will begin experiencing systemic fatigue, unexplained heavy legs, and declining performance despite training hard.

[!IMPORTANT]

Stage 3: Iron Deficiency Anemia

Both Hemoglobin and Ferritin have collapsed. Red blood cell production is compromised. Performance falls off a cliff, and you require immediate medical treatment (often infusions or heavy supplementation) to recover.

---

Symptoms of Iron Deficiency

Physical

• Fatigue (beyond normal training tiredness)
• Weakness
• Cold hands/feet
• Pale skin, especially nail beds
• Shortness of breath
• Increased heart rate

Performance

• Declining performance despite training
• Can't hit paces that used to be easy
• Poor recovery between workouts
• Hitting a wall in training

Other

• Brittle nails
• Hair loss
• Craving non-food items (pica)
• Frequent illness

---

Testing Recommendations

Key Tests

• Ferritin: Storage iron (most important marker)
• Hemoglobin: Part of complete blood count
• Serum iron: Circulating iron
• TIBC: Total iron-binding capacity

What to Ask For

"I'd like to have my iron levels checked, including ferritin."

Optimal Levels for Athletes

Test	Standard "Normal"	Athlete Optimal
Ferritin	12-150 ng/mL	35-50+ ng/mL
Hemoglobin	12-16 g/dL	13-14+ g/dL

Note: "Normal" doesn't mean optimal for performance.

When to Test

• Baseline at start of season
• If experiencing symptoms
• Every 3-6 months for high-risk athletes
• Before major training blocks

---

Dietary Iron Sources

Heme Iron (Well Absorbed)

Food	Iron	Notes
Beef (3oz)	2-3mg	Very well absorbed
Chicken thigh (3oz)	1mg	Dark meat better
Oysters (3oz)	8mg	Highest
Shrimp (3oz)	2mg	Good option

Non-Heme Iron (Less Absorbed, Still Important)

Food	Iron	Notes
Fortified cereals	18mg/serving	Check labels
Spinach (1 cup cooked)	6mg	Pair with vitamin C
Lentils (1 cup)	6mg	Good plant source
Beans (1 cup)	4mg	Versatile
Tofu (1/2 cup)	3mg	Firm tofu best

---

Optimizing Iron Absorption

Enhancers (Pair With Iron)

• Vitamin C (citrus, tomatoes, peppers)
• Meat eaten with plant iron
• Acidic foods

Inhibitors (Separate From Iron)

• Calcium supplements and dairy
• Coffee and tea
• Phytates (whole grains, legumes)
• Antacids

Practical Strategy

• Take iron supplements separately from calcium
• Wait 1-2 hours between iron and coffee/tea
• Add lemon/orange to iron-rich foods

---

Supplementation

When Supplements Are Needed

• Ferritin below 35 ng/mL
• Symptomatic iron deficiency
• Can't meet needs through food
• Under medical supervision

Types of Iron Supplements

Type	Absorption	GI Side Effects
Ferrous sulfate	Good	Higher
Ferrous gluconate	Moderate	Moderate
Ferrous bisglycinate	Good	Lower
Iron IV	Fastest	Medical setting

Dosing

• Typically 30-60mg elemental iron
• Every other day may be as effective as daily
• Takes 3-6 months to restore stores
• Retest after 3 months

Side Effects

• Constipation
• Nausea
• Dark stools (normal)
• Take with vitamin C, not with calcium/coffee

---

Prevention Strategies

Dietary

• Include heme iron regularly (red meat 2-3x/week)
• Fortified cereals
• Vitamin C with meals
• Avoid coffee/tea with iron-rich meals

Training

• Gradual mileage increases
• Prevent overtraining
• Adequate recovery

Monitoring

• Regular testing
• Know your baseline
• Track symptoms

---

Quick Reference

Warning Signs

• Unexplained fatigue
• Declining performance
• Unusually heavy periods
• Pale appearance

Key Actions

• Get ferritin tested (not just hemoglobin)
• Aim for ferritin 35-50+ ng/mL
• Include heme iron sources
• Pair iron with vitamin C
• Supplement if needed

---

Questions? Reach out at aspireperformancerd.com — I work with teams and individual athletes across Colorado.