Featherstone Nutrition

Dealing with acute, short-term LEA can be frustrating enough, but if it continues for longer periods of time, you might start to notice more serious health issues developing and bigger drop-offs in your training and recovery. As with inadequate vitamin D and calcium intake, chronic LEA increases the risk of low bone mineral density and decreased bone strength, contributing to a higher incidence of stress fractures. If you’re already dealing with a bone injury, consuming inadequate calories and lack of solid nutrition can slow your healing process. RED-S might also elevate your chances of developing other overuse injuries.

In last week’s post, I shared that 30 kcal per kilogram of fat-free mass (FFM) or less was considered to be the danger zone for LEA. While this is a good clinical rule of thumb, some studies have shown that women who were above this threshold still had menstrual functions that were all over the map. Researchers from Penn State found that multiple kinds of disturbances – including luteal phase defect, anovulation, oligomenorrhea – can become more frequent when female athletes have persistent energy deficits. 

According to the International Olympic Committee, RED-S doesn’t merely compromise bone health and disturb the menstrual cycle. Persistent LEA can also cause a whole host of health issues and exacerbate existing ones in many other body systems. Some of the long-term effects include:

Endocrine

• Disrupted levels of estrogen and progesterone in women
• Low testosterone in men

Metabolic

• A 2015 study on the female athlete triad (the interrelationship between LEA, menstrual function, and bone mineral density) found 53 percent of LEA participants had a decreased resting metabolic rate (RMR). Others were struggling with low bone density, high cholesterol, and low blood sugar   
• Impaired ability to use glucose effectively and sometimes low blood glucose levels 

Hematological 

• Low ferritin and iron deficiency anemia 
• Iron deficiency can further decrease appetite

Cardiovascular 

• Higher lipids
• Cardiac abnormalities like lower or higher heart rate

Gastrointestinal 

• Delayed or faster gastric emptying
• Diarrhea and constipation

Immunological 

• Increased risk of illness
• Decreased immunity

Psychological 

• Depression and anxiety
• Mood disturbances 

Growth and Development

• Stunted growth in adolescents
• Decreased growth hormone release

When someone finds out they have RED-S, the logical conclusion is that they simply need to eat more. This can certainly be the case, as having an overall calorie deficit is a major part of the problem. However, a bit more nuance is usually needed to remedy the issue, which is where a dietitian can help. When I look at a client’s eating habits across an entire day, I often see that there are certain times when they aren’t taking in enough energy, leading to lopsided energy intake over a 24-hour period and an overall deficit. 

For example, perhaps your mornings are crazy because of your commute or school drop-off, so you often skip breakfast. Or maybe work gets so busy that you don’t eat lunch several days a week. So by the time you get to midafternoon, you’re already energy deficient. Then you go and run hard, digging an even deeper hole. Once you’ve had help to pinpoint specific fueling gaps, you can start to fill these so that you have enough energy for daily life and training. 

A qualified professional can confirm whether or not you have RED-S or are struggling with LEA, and then create a comprehensive plan to help you bounce back. In addition to identifying gaps in your eating schedule, they can suggest better choices for snacks and meals, recommend supplements if needed, and take into account the big picture of your training, recovery, and lifestyle to help you find a more sustainable energy balance. As I wrote in a previous post, it’s time to stop being scared of carbs and embrace a well-balanced approach to nutrition.  

Sometimes the solutions to low energy availability are simple ones, such as incorporating more calorie-dense foods. For example, you could start adding a couple of spoonfuls of nut or seed butter to your post-workout shower shake. Frequency is another easy variable to change, as adding morning and afternoon snacks will increase your energy intake. Some of my clients have also benefited from eating a pre-bedtime snack, like a Greek yogurt parfait with berries & granola. Others have started eating a second breakfast. Ultimately, you have to fuel like you hope to perform, live, and recover. 

Most people’s eating is primarily directed by their appetite, but remember that this is often a lagging indicator of needing energy and can be disrupted by your sleep pattern, exercise, caffeine, and other factors. You’ll be better off planning for your fueling needs like you would build out your training sessions. A good rule of thumb is to fit in at least three meals and two snacks each day, not going more than 3 hours without eating and focusing on balancing adequate carbs, protein & fat. While it’s important to get enough carbs and protein, they only contain four calories per gram, whereas fat has nine, making it an easy way to up your energy intake.   

Also make sure you surround your energy expenditure – whether that’s a formalized session like a run or gym workout, or family activities – with more nutrition. In other words, eat before, during (when needed), and after exercise, and recognize that more intensity and volume will increase your fueling needs, such as if you start strength training or doing some two-a-days. It’s easy to get discouraged if you have RED-S/LEA but know that you have the power to overcome this and that there are people out there with the passion and knowledge to help you recover. Some of my clients have reported starting to feel and perform better in a few days once they increase their energy availability. 

If after trying these tips you still can’t keep up with your energy needs, then try cutting back on your training temporarily. Then when your schedule and lifestyle allow, scale up your workouts and nutrition again simultaneously. 

If you’re struggling with LEA or RED-S and need help, please reach out. I’ve helped many clients to overcome this issue and would welcome the chance to get you back on the path to optimal performance and health.

Finding yourself in a calorie deficit occasionally probably isn’t going to be a problem, if you recognize it and make changes. But when you consistently have insufficient energy intake or the amount of energy you are expending is far greater than your intake, or both you might have low energy availability (LEA) which could lead to RED-S. According to a consensus statement by the International Olympic Committee, “LEA, which underpins the concept of RED-S, is a mismatch between an athlete’s energy intake (diet) and the energy expended in exercise, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance.”

As a result of this mismatch between how much energy your body needs and how much you’re giving it, you can begin experiencing health issues, a performance drop-off, and inadequate recovery, as your body struggles to find ways to get the energy it needs for basic functions while also fueling your training and recovery. The IOC paper defined RED-S as “impaired physiological functioning caused by relative energy deficiency, and includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health.”

One of the ways that registered dietitians and other practitioners try to identify whether someone is suffering from RED-S or a similar condition is by calculating their energy availability. Calculating food energy intake minus exercise energy expenditure equals energy availability. The leftover ‘energy availability’ must be enough energy for your body to fuel basic physiological processes.

For many athletes, they need to be consuming 45 kcal/kg FFM (fat-free mass) at baseline + recouping any energy needed for training. An energy availability of 30 kcal/kg FFM or below, is called ‘low energy availability.’ This means the amount of calories you’re consuming cannot support your daily energy needs plus the fuel your body requires during and after exercise. The deficit compromises body systems that need fuel, which start to shut down to preserve energy and keep you alive.

Calculating your exact FFM is difficult and not accessible to most people. FFM is measured or estimated by dietitians or medical professionals – so if you are concerned in this area, please reach out to your sports dietitian or physician.

There’s a reason that the S in RED-S stands for sport. Whether you’re a runner, cyclist, triathlete, or dabble in multiple disciplines, the more active you are, the greater number of calories you’ll burn. It isn’t just about your energy needs during training either. Your body needs extra fuel to support recovery and lean muscle mass is more metabolically demanding. Plus, there are many energy-dependent processes your body and brain need to perform to keep you functioning. Overlooking these factors is why some athletes drastically underestimate their fueling needs and can slip into chronic energy deficiency. Studies on runners suggest LEA (low energy availability) is most prevalent with high training loads, high energy expenditure, and low energy intake. A sudden increase in mileage and/or intensity, changing nutrition choices or restricting new foods, lack of hunger cues or decreased appetite with higher training loads, and competing in more races could all put an athlete at greater risk for RED-S if they are not conscious of proper fueling.

While chronic energy deficiency is more prevalent among women, male athletes can suffer from RED-S (see recent Ryan Hall post). Reasons can include societal pressure to look a certain way as a runner or endurance athlete, advice from a coach that leaner improves race times, lower caloric intake to begin with, disordered eating, lack of knowledge on how to fuel your body for your training load, and an energy deficit from pursuing a new dietary pattern and restricting foods or times of nutrition.

It’s a misconception that only people who are battling eating disorders struggle with RED-S. RED-S isn’t always paired with disordered eating, fear of consuming too many calories, or other unhealthy perspectives toward food. One of the most common causes I see among my clients is unintentional underfueling – that they simply underestimate the amount of fuel they need to power their performance and recovery, while also meeting their daily energy needs.

Sometimes, RED-S presents several warning signs that pop up like an engine light in your car. However, researchers from the University of North Carolina found that when observing male athletes with RED-S,  “participants displayed no major hormonal or bone health disturbances” in the short term. This means that it could be harder to pinpoint the condition in men than in women, who often start to experience changes in their period and/or stress fractures (more on the long-term effects of RED-S to come in part two). That being said, an article by Brown University stated that “This often unrecognized disorder can include low energy availability (inadequate caloric intake); with or without disordered eating; amenorrhea (lack of menstrual periods); and low bone mineral density.” In other words, RED-S can go undiagnosed in women too.

When red flags do appear, they typically impact performance and recovery first, and then begin to extend into overall physical, mental, and emotional wellbeing. Common symptoms of RED-S include:

• Poor performance (such as inability to hit or hold paces, quicker time to exhaustion, and increased perceived effort)
• Delayed recovery 
• Decreased power and strength output
• Chronic fatigue
• Feeling heavy, lethargic, and low on energy
• Loss of bodyweight and muscle mass
• Sleep disturbances
• Nagging injuries
• Disrupted menstrual cycle and/or missed period
• Emotional volatility and irritability 
• Change in appetite
• Delayed recovery
• Lower heart rate variability (HRV)

Check back soon for part two in this series, when we’ll explore what you can do to reverse RED-S (hint: it might be easier than you think, and you CAN come back from this!).

Vitamin D helps us absorb calcium and phosphate from our intestines and then helps to regulate their storage & blood concentrations throughout our body, making it essential for the formation of new bone and the preservation of existing skeletal mass. Without enough Vitamin D, our bones can become brittle. Vitamin D is also involved in both innate and adaptive immunity, according to a team of British and Canadian researchers. It’s also involved in cardiovascular health and has a neuroprotective effect on the brain.

It’s arguable that vitamin D is the most prevalent micronutrient deficiency. While many other vitamins and minerals can be consumed through a well-rounded diet, vitamin D’s production is mainly prompted by exposure to direct sunlight, and specifically UVB rays. We’ll look at some food sources in a moment, but Vitamin D is not prevalent in the foods we eat most often.  Combine that with the fact that American adults spend the majority of their time indoors, and it’s little wonder that up to 90 percent of the population is vitamin D deficient, per a paper published in Frontiers in Physiology.

One would assume yes, but the research on vitamin D shows that even people who are active in sunny, warm climates have a high rate of deficiency. This is particularly prevalent in the Northern Hemisphere during winter, as the weak sun, cloudy weather, and early sunset conspire to keep us from synthesizing enough vitamin D. Plus, if you’re training in cold wintry conditions, you’re most likely layering up and covering parts of your body – like your hands and head – that are open to the sun at other times of year. Or, if you’re always running before the sun comes up, no Vitamin D production there. So just running outdoors might not be cutting it from a vitamin D standpoint.

Vitamin D deficiency often has no symptoms at all. Symptoms may include fatigue, bone pain, muscle weakness, or mood changes. As some of these can be linked to other issues and multi-factorial, I often encourage my athletes to get a blood panel that includes serum vitamin D. I typically recommend that my athletes target 40 ng/mL or more. Anecdotally, around 75 percent of my athletes tested who are not supplementing have low Vitamin D. 

Insufficient vitamin D puts you at greater risk of getting sick and could prolong certain symptoms, which is not helpful from a performance standpoint. If you have a bone injury, it may take longer to heal if you have insufficient levels of Vitamin D. But perhaps the most concerning side effect of low vitamin D is the elevated incidence of stress fractures. 

A study of 802 NCAA Division 1 male and female athletes discovered that they increased their risk of stress fracture by 12% when their serum vitamin D was lower than 20 ng/mL and/or they didn’t take a vitamin D supplement, when compared to those whose serum vitamin D levels were >40 ng/mL and athletes with low vitamin D who were supplementing. The authors wrote that “Low vitamin D levels along with high-intensity athletic training may put an athlete at increased risk for a stress fracture.”

If you know or suspect that you’re lacking in vitamin D, researchers from the University of Wyoming suggest a three-part strategy. First, try to get outside in direct sunlight for 5-30 minutes between 10 am and 3 pm as often as possible, as this is the easiest way to stimulate your body’s production. Skip the sunscreen for this short duration and try to get your sun session at least twice a week. (Note: We are not suggesting to skip your sunscreen altogether – as little as 5 minutes per day can help improve Vitamin D levels. If you are at high risk for skin cancer or have other skin conditions, this may not be an option for you, please consult your physician.) You can also try to eat more salmon, mackerel, tuna, and other oily fish, along with plenty of eggs (don’t toss the yolks!). As a bonus, these all provide inflammation-fighting omega-3 fatty acids. Animal foods like these contain D3, the most readily absorbed form, as do some fortified products like milk and cereal. Plant-based sources include leafy green vegetables, sesame seeds, and mushrooms, but these are in the D2 form, which has less bioavailability. 

Even the richest food sources are unlikely to supply the consistent amount of vitamin D you need, which is where a third tactic becomes useful: supplementation. 1,000 to 2,000 IUs of vitamin D3 per day is a solid starting point. Your doctor or dietitian might recommend more, depending on your situation. The NCAA researchers noted that if you’re low in vitamin D, supplementation helps elevate serum levels and reduces the risk of stress fracture. 

When you’re working out in hot and/or humid weather, getting enough fluids and replenishing your electrolytes can be tricky because of the conditions and the amount you’re sweating. But at least the need to hydrate is pretty obvious because of what you feel and observe about your body, and to keep you alive, your body’s thirst mechanism is finely attuned when it’s warm. But when the mercury plunges, you probably don’t feel hot and clammy and can’t see the sweat on your skin, so you’re without the usual cues that prompt you to drink. 

A team of researchers from the University of New Hampshire found that during moderate exercise (at around 50 percent of VO2 max) and at rest in the cold, participants’ thirst sensation dropped off by up to 40 percent, which they speculated might be because of peripheral blood vessels constricting. In other words, drink to thirst tactics that serve you well for the rest of the year aren’t as effective during winter.

At first glance, it might be tempting to look at the winter thirst study and think that maybe the people involved were just using way less water. But in fact, the typical recommendations for around three liters of fluid intake per day that the National Academies of Sciences outlined (while noting that this is merely the median in their data and that individuals’ needs vary based on activity level, bodyweight, and other factors) hold true all year long. Sure, you might not be sweating as much as at the peak of summer, but exercise still drains your fluid reservoir and you need enough water to also preserve the function of your nervous, cardiovascular, musculoskeletal, and other systems during daily life.

For many athletes, it should be enough to know that although you don’t feel or see sweat as obviously when it’s cold, you’re still sweating and internally, your body is using fluid just like it does in warmer weather. But maybe you like to quantify your physiology and training and want to explore your own seasonal hydration variations. In which case, you could use a simple sweat rate calculator like the one on my website to dig a little deeper. Or if you have a continuous hydration monitoring device such as an hDrop, you could use this during your runs, rides, and gym workouts to objectively measure your sweat rate and composition. 

Also take into account that the amount you sweat and how many electrolytes you lose can be altered by many factors, per a paper published in Sports Medicine. Whether you’re training outside on roads, trails, or a track or inside on a treadmill will likely make a difference, as will your layering strategy when you’re outdoors, the volume and intensity of your training, and other factors. The key is to experiment with all these variables and then dial in your fluid intake accordingly to ensure you’re getting enough fluid.

You might not want to take it as far as quantifying your winter hydration needs. In which case, following a few generic rules of thumb may be sufficient. Here are some best practices I suggest to my clients: 

• Start your day with 16 oz of fluid like water, coffee, tea, or a sports drink (or a combination of these)

• Keep a water bottle full of fluid with you throughout the day

• Drink water with meals and snacks

• Take fluid with you on runs lasting over 1 hour 

• Rehydrate after runs and workouts

Remember that these are merely guidelines and be sure to adjust them based on what’s working well and what needs to be tweaked. You’ll know you’re not getting enough fluids if your performance drops off, you struggle to bounce back between sessions, or you start feeling off in general. In addition to drinking plenty of water and using your usual sports drinks before, during, and after longer lifting and endurance sessions, you can also top up your fluid levels through your diet. Most fruit and vegetables have a high water content, making them the perfect complement to your winter hydration strategy.

A lot of clients come to me when they’ve decided to commit to training and racing and have big goals. This could be a new thing for them, and they might not know how to fuel the increase in mileage and intensity that a new program demands. Or, perhaps a more seasoned athlete who has been competitive for several years could be working with a running, cycling, or triathlon coach, have dialed in other areas of performance, but never focused on nutrition. Another reason why people reach out is that they’re struggling with a serious acute or chronic injury and think that eating better could help, but don’t know how. Or maybe they are stuck on a plateau or have seen their training paces and finish times stall.

1-on-1 coaching is great for anyone looking to improve their nutrition and is also looking for accountability and a personalized approach. One of the advantages is that you’ll receive more dedicated and personalized attention from me on an ongoing basis. We’ll also be able to take a comprehensive view of your previous training, racing, and injury history and see exactly where you’re at currently with your eating and supplementation. Then we can map out a plan for how to move forward to reach your goals. This is a good option if you do better in 1-on-1 conversations, rather than in a group setting, have a complex medical history, or feel like you need more accountability. 

Depending on the package you choose, we’ll have weekly calls or email check-ins. These will be very personalized to your needs, lifestyle, and goals. We can focus on performance nutrition, hydration, body composition, food allergies, or whatever you need. Over time, we can change directions or explore other areas as needed. I believe in creating lasting relationships that continue to deliver long-term value and welcome the chance to team up. 

If you’re interested in a personalized, 1-on-1 plan, the first step is to complete an application to get on the waitlist. Then as soon as possible, our team will contact you to get going once a spot opens up.

Clients often come into one of my nutrition coaching groups seeking the education and community that a team environment provides. It’s an opportunity to not only learn about and apply sound nutritional principles to training, racing, and life, but also to develop new friendships and a lasting support system. Athletes who’ve typically trained alone often come alive in this group setting, as they welcome being part of a tight-knit community of runners who are pursuing similar performance goals. This option might be best if you need more encouragement, like to hear other people’s suggestions and experiences while sharing your own, and respond well in a class environment. 

My group program features weekly live classes taught by me, which are also recorded in case you have a scheduling conflict or want to re-watch a session later on-demand. Each class topic focuses on an aspect of performance nutrition and hydration that will prepare you to train for and race in half and full marathons. In addition to class sessions, there are weekly slides, tools, and homework to supplement the course content. We offer support via a private Slack channel and there’s an opportunity to be as much or as little involved as you like and your lifestyle allows. 

We have new race and distance-specific groups opening up now for 2023. Fueled for Boston is for anyone running Boston 2023, and we’re also offering spring half or full marathon coaching that’s best for races after April 11, 2023. Click here to learn more and sign up today!

No matter what level of nutrition coaching you are looking for, we have something for you! Not interested in coaching just yet but want some help gearing up for a specific race? Take a look at our Customized Nutrition Plans or apply for a one-time consultation. And make sure you are taking advantage of our free resources: Instagram, carb loading, hydration, race day fueling & recovery.

Unless you’re gearing up for an early 2023 race, you might have eight to 12 weeks (or more) of downtime, which provides you with the perfect opportunity to dial in your nutrition. During racing season, it’s difficult to do much around body composition because you’re fueling for performance in training and competition. But now that there’s less mileage, intensity, and frequency for a while, you’ve got more bandwidth to focus on other elements of your overall well-being.

The key is concentrating on healthy eating. This isn’t the same as dieting, which implies restricting or eliminating certain foods and attaching unhelpful “good” or “bad” labels. When people diet, it puts the focus on the scale and eliminating certain foods or food groups. In many cases, it is extremely harmful and can start to create compulsive behaviors and obsessions, not to mention, these restrictive diets are not sustainable. You’ll be better off setting a goal that isn’t weight-centric, such as increasing lean muscle mass, getting stronger, or feeling better in certain clothes.

A good starting point when you’re targeting body composition changes is to evaluate your current meal and snack patterns. Which areas are you nailing, like sticking to consistent eating times? And is there something you could get better at, such as including protein with every meal? Once you’ve assessed what you’re doing currently, you’ll have a better understanding of what needs to change, what you can keep the same, and what you can double down on.

Some of my clients have an intuitive feel for what they’re eating and when, while others struggle to get a handle on what their eating patterns look like from day to day. If you fall in this second category, you might find it helpful to see where you’re at and what you could tweak. Don’t get fixated on every single detail, start weighing your food, or count calories, but rather stick to the basics of recording meals & snacks, timing and monitoring feelings of hunger, satiety, and boredom related to your food.  If you’ve struggled with disordered eating or anxiety, tracking probably isn’t the best approach for you.

It might seem counterintuitive, but big body composition wins can come from just a few small changes. For example, if you often skip breakfast because your morning is hectic or fitting in lunch around your work schedule is tricky, you might overeat later to try to compensate. In which case, getting intentional around eating those essential meals every day is an easy fix. The off-season can also be a good time to get back to eating things you’ve missed, like big salads or extra veggies. You might have more time to cook and bake if you’re training less, which could allow you to make some new snacks like pumpkin spice and mint chocolate energy bites and gingerbread blender muffins that will keep your energy level high between meals and power you through your off-season workouts. If you find that you’re not getting the right balance of carbs, protein, and fat, you could start trying to include all three in each meal.

Recently, I’ve had a lot of people writing to me via Instagram and the Fuel for the Sole podcast asking questions about their nutrition at this time of year. This led me to create a new Off-Season Body Composition Series. It features four virtual classes that you can watch and replay at your convenience. Then you’ll get homework that will guide you on what to evaluate and focus on before the next class. 

We’ll cover how to evaluate body composition, take genetics into account, and set goals in week one. Then in week two, we’ll review macronutrients and look at how to better balance meals and snacks. Moving into week three, you’ll learn how to spot behaviors you can change and when to create new ones that support your healthiest body comp. Finally in week four, you’ll discover the reasons that your weight might fluctuate, which goals it’s better to focus on instead, and how to chase them effectively. 

This is NOT a weight loss course or crash diet. It’s a way to empower yourself to self-identify your strengths, find controllable factors you can improve, and forge sustainable habits for life. If you commit to practicing these consistently, then you’ll get the positive changes that you’re hoping for – not only in your body composition, but also your performance and overall health. 

Sign up now for the Off-Season Body Composition Series, and we’ll send you the first class right away. You’ll then receive the remaining three over the coming weeks. 

One of the reasons that Thanksgiving, Christmas, New Year’s, and all the time in between can become so tricky from an eating standpoint is that many people cut certain things out of their diet completely for most of the year. Then when the holidays roll around, it’s a free-for-all, as if they fear never having these “bad” things again once the season ends. So instead of incorporating favorites foods into their diet, they overindulge for a few weeks, which can lead to feelings of guilt during and after the holidays.

Labeling foods or drinks as “good” or “bad” is subjective and not something that I recommend. While it’s true that some options are healthier than others, eating a little of most things is very unlikely to torpedo your overall health or performance, particularly if you maintain a balanced approach to eating well overall throughout the year. 

At my house, we have a tradition of making frosted sugar cookies around the holidays. We eat a few, freeze some more, and relish every last bite. You should give yourself permission to enjoy whatever food-based traditions your family has created. If you’ve normalized these treats, then you won’t go through mental anguish, will savor the flavor and experience more, and won’t feel pushed to overeat something that you’ve labeled as forbidden.

One of the common challenges many people share about their holiday nutrition is sporadically going too far and over-consuming their festive favorites. When I dig a little deeper, I usually find out that this is preceded by them not eating enough or foregoing a meal altogether because they’re expecting to binge. Going too long without eating will inevitably compromise your willpower and planning to over consume will set you up to do just that. Even if a relative is planning a huge family feast at lunchtime, make sure that you eat a normal breakfast – because skipping that meal will leave you too hungry and more likely to overeat at your holiday gathering.

Another mental challenge that seasonal eating presents is that people can come to expect a drastic yo-yo effect every time Christmas approaches. First comes cramming cookies, cakes, and other sweet treats for a few weeks, quickly followed by rigid self-denial or cutting out certain types of foods (i.e. gluten, sugar, dairy, etc). This sharp contrast can create emotional & mental anguish, undermine positive habits you’ve spent all year building up and also mess with your hunger cues and metabolism.

Fortunately, it doesn’t have to be like that. If you can keep nailing the basics of nutrition that you normally stick to, you’ll have a much better holiday experience and avoid unnecessary upheaval. Tips for eating during the holiday season:

Once you’ve gotten the blood panels we recommended, it’s helpful to work with a dietitian to interpret the results, look at the broader context of your training and lifestyle, and if you’re low in ferritin and iron, come up with a plan to remedy that. Getting the data is necessary but interpreting it the right way is even more important. This is important: We don’t ever want to blindly start an iron supplement – it can be dangerous if your iron levels get too high. I highly recommend consulting a dietitian or doctor prior to starting any iron supplement.

As I wrote in part two of this series, the clinical range for an acceptable ferritin level is very broad – 10 – 120 ng/mL for women and 20 – 250 ng/mL for men. But from an endurance performance standpoint, the baseline should be 40 ng/mL, or 50 ng/mL if you live at high altitude or are planning to train in it. If your panels come back with lower numbers, it’s probably wise to start supplementing and getting more iron in your diet.

There are two kinds of iron found in food. Meat, fish, and other animal products contain heme iron, which is more readily absorbed. Solid sources include shellfish, beef, bison, lamb, turkey, ham, and eggs. Plant foods have non-heme iron instead, which is found in chard, kale, collard greens, spinach, broccoli, sweet potatoes, pumpkin seeds, brussels sprouts, nuts, lentils, and dark chocolate (bonus!). Fortified cereals and other foods also contain non-heme iron.

There are some substances that can enhance the amount of iron you get from your diet. You’d do well to pair iron-rich foods with those that contain vitamin C, like peppers, citrus fruit, and kiwis because it increases absorption. Fermented products like kombucha, kimchi, and dill pickles also seem to increase iron uptake, as does alcohol. Another sneaky tactic is to use a cast iron skillet to cook with. A study conducted at Texas Tech University found that cooking spaghetti sauce in this kind of pan increased participants’ iron uptake by 2 mg, while they got 6 mg more from apple sauce. 

Things that interfere with iron absorption include calcium, magnesium, zinc, soy protein, phytic acid found in some grains, nuts, and seeds, and, sadly for the caffeine crowd, tea and coffee. It doesn’t mean that you should avoid any of these – just try spreading them out a bit from your iron-rich meals.

As a registered dietitian, I always encourage clients to look to their nutrition first, if possible, and then utilize supplements. The recommended intake for iron is 8mg for men, 18mg for menstruating women, 27mg for pregnant women, and 8mg for post-menopausal women. So, as you can see, many women need several to many high iron foods per day, which is difficult for many people to consume. There’s another challenge, in that your body can only absorb 15 – 35% heme iron from animal sources, and just 10 – 15% of non-heme iron from plant-based foods. That’s why you may need to pair iron-rich nutrition with supplementation to get your ferritin and iron up. 

Other reasons food alone may not be enough include if you’re extremely low in ferritin and iron, are training hard, are planning to train or race at altitude, or have a lot of extra life stress. If you’re vegetarian or vegan, you may need a supplement because the iron you’re getting from non-heme foods probably isn’t sufficient.

There’s a pretty broad range of potency with iron supplements, from 20 to 85 mg or more. How much you take depends upon what your diet looks like and how low your levels are. As with most supplements, it’s best to start with a low to moderate dosage and then build up from there if needed. A review out of Cornell University found that supplementing with just 20 mg a day increased iron stores, leading to improved performance and health outcomes. 

In terms of timing, one hour before a meal or two hours afterward seems to be a sweet spot. A study published in Medicine & Science in Sports & Exercise found that if you run in the morning, taking your iron supplement afterward will increase iron absorption. Like I advised for food-based iron, avoid taking your iron supplement with others that contain magnesium, calcium, or zinc, as it will reduce absorption. This is why a standalone iron supplement is better than a multi from an iron perspective. Conversely, if you take vitamin C, you could do so with iron to increase absorption. 

There can be side effects from taking iron – most typically constipation and GI distress. If you struggle with these, then cut back your intake or split it into two at different times of day. As heme iron is better absorbed, you might be able to take a lower dose of it than you would with the non-heme kind. Some supplements have a combination of both, and others are slow release, which can be gentler on your stomach. You can check out some of the products I use and recommend here.

People can start to notice positive changes with certain supplements like vitamin B12 almost right away. But iron stores take longer to increase, so don’t expect a “wow” factor after a day or two. Consistent daily iron supplementation should start to make a difference in about two weeks, and a month in, you may observe noticeable impact on your performance and recovery. However, for some people, it will take months for ferritin levels to increase, so be consistent & patient.

I’ve worked with enough athletes to suspect when someone is low on iron, especially when they’re dealing with performance shortfalls, persistent fatigue, and some of the other symptoms we mentioned in part one without any other probable explanation. But I always like to have confirmation for my hunch by having my clients get bloodwork done. We always, always, always want to check our labs prior to supplementing, so we know that we are treating and supplementing correctly. 

Your primary care doctor can order labs to be drawn, whether it’s in-office or they send you to a lab. This option will likely be the most cost-effective if you have health insurance. Other options are to order your own labs from somewhere like Quest Diagnostics or Inside Tracker. Try to make sure you wait at least 48 hours after a race or hard training session before testing so you don’t skew the numbers. Once the panel has been drawn, you should get the results fairly quickly. 

There are several iron-related labs that can be checked. While ferritin is a common indicator of iron stores, it can give a false reading if you’ve been sick or under intense training or lifestyle stress. In which case, other markers can be useful. It’s also helpful to see the “whole picture” when it comes to iron labs <aka not just looking at one stand alone lab value>, so it’s important that you ask for CBC, iron panel and ferritin.

Once you get the test results back, you’ll want to know whether your ferritin level is low, high, or just about right. The tricky thing is that the range is very broad – what’s considered to be “normal” at your doctor’s office is 10 – 120 ng/mL for females and 20 – 250 ng/mL for males. However, in running, cycling, swimming, triathlon, and other endurance disciplines, performance is usually optimized at or above 40 ng/mL, per a study by Japanese exercise scientists and other papers. At altitude, this can rise to more than 50 according to a study by Swiss researchers, as at higher elevation we need more oxygenated blood to sustain pace and power output. To make it even more complex, optimal ferritin levels can vary from person to person – Person A may feel great with a ferritin of 40 ng/mL, while person B might need theirs at 50 ng/mL.

There could be different parameters than your physician is currently not aware of – you’re probably the healthiest person they’ve treated all day, and labs within normal limits are typically a good sign. However, just because your iron levels are within normal limits for baseline health doesn’t mean that they’re optimized for endurance performance – the two goals are completely different. Your doctor isn’t wrong, but may only be looking at your ferritin and other iron markers through a lens for an average <sedentary to mildly active> adult. 

It’s this kind of contrast that shows why you might benefit from working with a registered dietitian or other specialist. Just having blood test data is only the first step – it’s what you do with the information that’s most important. So you need someone who has the right knowledge & experience to interpret the results, take into context your training and medical history, nutrition, and other factors, to help you come up with a plan. 

As levels of ferritin and other iron markers fluctuate over time, a one-off test might only give you a snapshot view of your body’s stores. Here’s a suggested frequency if you’re interested in ongoing testing that might enable you to keep tabs on your levels so you can address deficiency and even make pre-emptive changes if an initial panel shows a decline. 

Annually:  Once a year might be fine if you do not have a history of iron deficiency, and you have been feeling well during training and races.

Biannually: A test every six months might be better if you have a slightly low ferritin and are trying to increase with high iron food, are a female endurance athlete, or have the intention to increase training or head to altitude within the next 12 months.

Quarterly: Getting a panel every three months is advisable if you have a long history of iron deficiency, are currently supplementing trying to get an increase in ferritin, are vegetarian/vegan, see evidence of low energy availability, are continually training at high volume and intensity, struggle with ongoing fatigue/lethargy, or plan to train at altitude within six months.    

Ferritin is a blood protein that is your body’s preferred storage form of iron, which it releases as necessary. Around 25 percent of all the iron in your body is typically contained in ferritin. The demand for iron goes up when you’re training or racing because it’s the building block for hemoglobin in the bloodstream, which delivers oxygen from the lungs to your muscles via red blood cells. Iron is also needed to regulate myoglobin, a protein found in muscles that binds to and releases oxygen, and cytochromes, a key catalyst of energy production. It plays a part in immunity, DNA synthesis, pH balance, and many other processes too. Unlike some other micronutrients, your body cannot make its own iron, so you have to take it in through food and/or supplementation.

According to a study on female basketball players, “Athletes experience disturbances of systemic iron homeostasis, especially during training periods characterized by intense training loads.” The authors stated that iron in female athletes can be twice as low as in sedentary groups. It’s also arguably more common. A review published in the European Journal of Applied Physiology stated that five to 11 percent of male athletes tested in previous trials were low on ferritin, which is an indicator for inadequate iron. This rose to a whopping 15 to 35 percent of female athletes. Other studies have pegged these numbers even higher, suggesting that up to 56 percent of female endurance athletes have insufficient iron stores. 

So why is this? We can lose iron through sweat and urine, the GI tract, frequent use of NSAIDs, and a phenomenon known as foot-strike hemolysis. This occurs when red blood cells in the feet are destroyed as you pound the pavement or trail, which not only results in the loss of iron, but also needing to utilize more to repair the damage. That might explain why runners, basketball players, and athletes in other sports that involve a lot of ground contact have higher rates of deficiency. 

There are several reasons why low iron might affect more female athletes than males. First, some can be lost during monthly menstruation. Second, I see more women who are on vegan or vegetarian diets. While you can find iron in some plant-based sources, it’s more difficult to absorb because it’s in the non-heme form. Whereas fish, meat, and poultry all contain the more available form, heme iron. Those who eat fortified foods find it easier to boost their intake. The overall quantity of food female athletes eat may be significantly less than a larger male athlete making it harder to get sufficient iron. 

The authors of the basketball study wrote that “Insufficient reserves of iron in the body can reduce athletic performance, which may be manifested as fatigue, exercise intolerance, or even cognitive function impairment.” I often hear clients complain of not being able to hit or maintain their target paces in training, feeling like they’re exerting more effort than usual, hitting the wall sooner, and generally feeling heavy and lethargic. They might also notice decreased adaptation to their training and failure to recover fully between sessions. Increased resting and active heart rate, dizziness, and shortness of breath during exercise can become issues too. 

Certain sessions like sprints and intervals can become harder because power output declines and time-to-exhaustion is reduced when ferritin levels are low. Some athletes might experience irritability and other mood disturbances, find it hard to focus during workouts, or become apathetic and lose interest in training altogether. They could also start struggling with niggling injuries and more frequent bouts of illness. In these ways, iron deficiency can be mistaken for chronic overtraining, as many of the symptoms are the same.

How or if you respond to caffeine might seem totally random, but research shows that it’s actually hardwired into your genetics. A study published in Medicine & Science in Sports & Exercise stated that a variation in the CYP1A2 gene that regulates caffeine was likely responsible for three different outcomes in cyclists who consumed it. One group finished a time trial faster with two and four mgs per kilo of bodyweight, a second experienced no effect, and a third had a decrease in performance. The takeaway? Keep using caffeine if it helps you or you enjoy the taste of tea or coffee, but don’t force it if it doesn’t seem to do anything or makes you feel worse.

Caffeine is a central nervous system stimulant that blocks tiredness-causing adenosine from binding to receptors in your brain, while stimulating the release of adrenaline, noradrenaline, and catecholamines, which include the so-called “happy hormone” dopamine. The International Olympic Committee (IOC) includes caffeine on a very short list of supplements that it states are backed by “good evidence of benefits,” along with creatine monohydrate, nitrate, sodium bicarbonate, and beta-alanine. 

Studies have shown that caffeine helps increase time to exhaustion, improve speed, and boost power output. The ways it does this include decreasing pain and the perception of effort and fatigue, which may help you push past your usual limit and keep going harder for longer. According to the International Society of Sports Nutrition, caffeine also has cognitive benefits, including increased vigilance, attention, and overall acuity, suggesting that it helps you maintain focus on your performance.

A Journal of Strength and Conditioning Research review of previous studies discovered that the impact of caffeine on endurance performance varies greatly, from a 0.3 percent decrease to a 17.3 percent increase. In addition to the genetic factor, they explained that caffeine consumption habits, timing, dose, and method of ingestion can all contribute to this variable impact. While your response is individualized, caffeine seems to peak in your system around 60 minutes after consumption, with the beneficial effects lasting around 1 hour. With this in mind, it’s important to consider when you’re going to use it with optimal timing for training and racing. 

Before you head out the door to run, it’s best to stick to your usual daily caffeine schedule, as your body and brain will get bamboozled if you’re used to a morning and/or afternoon cup of coffee or tea and suddenly avoid it. The same goes for race day. Conversely, if you don’t normally consume caffeine before a run, it’s not best to try it out for the first time prior to a long or hard session, or right before you show up to the start line. Nor should you jack up your caffeine consumption in the belief that if some is good, more must be better, as studies show that beyond a certain point there’s no extra benefit and you might actually start to develop jitters, tummy troubles, and other unpleasant side effects. 

In the IOC position paper, the authors wrote that “Caffeine consumption during activity should be considered concurrent with carbohydrate (CHO) intake for improved efficacy.” This is where caffeinated gels can come in handy. Again, there’s no one-size-fits-all prescription here, but what I’ve found to be effective for marathons and other longer races is to alternate caffeinated and non-caffeinated products. Three to six milligrams per kilogram of bodyweight before and during training and racing is the amount many studies have found increases endurance performance by 2-4%. 

This range is really broad, but 200 mg is a sweet spot for many runners. That’s two cups of coffee or two stronger gels, like Maurten Gel 100 Caf 100. Good products like this that have been vetted by NSF Certified for Sport or Informed Sport accurately list the caffeine amount, making your trial-and-error process easier. As with any supplement, start with a low dose and carefully build up as needed. 

Remember that it takes an hour for caffeine to fully kick in and that a lot of runners need it most in the second half of a race. So, if you were running a three-hour marathon and wanted to keep pushing hard in the last 10K, take a caffeinated gel at 60 minutes. Or if you’re on pace for four hours, caffeine at the one- and two-hour marks might help you finish strong. As I advised for your overall nutrition/hydration plan in a previous post, practice your caffeine strategy on long runs so that you iron out any kinks and dial in timing and total dosage to tap into the performance benefits on race day.

The biggest mistake I see clients making with their post-injury recovery nutrition is underfueling. This is often born of the belief that “I’m not training so I need to eat way less, right?” Wrong! Although you’re not moving as much so you won’t be burning through as much energy as usual, your resting calorie needs are greater than you think. This is due to having more lean mass and a higher metabolism than a sedentary person, plus, your body has nutritional needs to help repair the damage from your injury. 

Consuming adequate nutrition is imperative so you don’t sink into a calorie deficit, which can lead to delayed recovery, weight and muscle loss, hormone disruption, and more nasty side effects. A paper published in Nutrients stated that “During rehabilitation, simultaneous carbohydrates and protein intake can inhibit muscle breakdown and muscle atrophy.” This combo will also keep your energy level high, stabilize your mood, and support your healing process. 

When you’re injured, you actually need around 20 percent more protein to promote healing, which is why the study authors recommend getting as much as two grams per kilogram of bodyweight daily. Shoot for 20 to 40 grams per meal, adding in a complete protein supplement if necessary. The amount of carbs you need might dip a little, but they’re still your primary energy source, so include them in all meals and snacks and adjust portion sizes to take into account your lower activity level, without cutting back too far. 

The researchers also mentioned getting sufficient fat during your return-to-running process. This is valuable from an energy perspective, as it contains nine calories per gram versus four for protein and carbs. Fat is also used in the repair of joints and soft tissues. While you might not need quite as much total fat as when training hard, eating more omega-3 fatty acids can be beneficial. Initially, inflammation is necessary to prompt the healing process, but if prolonged, it can hinder healing. This is when omega-3s can be beneficial. They’re found in plant sources like flax & chia seeds, walnuts, and almonds; although, fish provides higher levels of EPA and DHA, along with micronutrients involved in the healing process, such as copper. You may consider a marine-sourced supplement daily to ensure you’ll get enough. 

Once you’ve moved out of the acute inflammation phase right after injury, tart cherry juice could be another useful supplement. Its active compound, anthocyanin can help decrease inflammation and reduce joint and muscle pain.

The two most common types of acute injuries suffered by runners are bone issues such as stress fractures and injuries to soft tissues like muscles, ligaments, and tendons. Both require the fuel supplied by the balanced diet described earlier. You can support the healing of a bone injury by ensuring that you get enough calcium, vitamin D, and vitamin K, all of which are vital to bone health and growth. Dutch researchers found that low vitamin D levels delay bone injury recovery, and other studies have shown that they greatly increase the risk of stress fractures. If it’s consistently sunny where you live, then you might get enough D just by being outside, but with winter closing in, you may need 2000 IU a day in supplement form just to be sure. If you are vitamin D deficient, you will likely need a higher dosage supplement. Fatty meats, leafy greens, and broccoli are all good sources of vitamin K, and some vitamin D supplements include it. If you eat 3 serving of dairy per day on average, you’re probably getting enough dietary calcium, and if not, look for fortified non-dairy alternatives or a calcium supplement. 

Soft tissue injuries typically heal quicker than bone damage, but blood flow to ligaments and tendons is much lower than to muscles, so they can be tricky to rehabilitate. Taking a combination of collagen – which is a key component of soft tissues – and vitamin C 30 to 60 minutes before whatever exercise you’re cleared to do can help. Australian researchers found that combining this supplement with calf strengthening exercises enabled participants to recover faster from Achilles tendinopathy. Vitamin A – which you can find in sweet potatoes, carrots, and bell peppers – also plays a part in collagen formation.