If there is one thing that’s been ingrained in all athletes, especially female athletes, it’s to watch out for anemia.
Ever feel weak, exhausted, have trouble breathing, get headaches, feel dizzy, or struggle with decreased exercise performance?
Back in college I started to feel this way my senior year, which was a big deal since I had big goals on how I wanted to finish my college running career. I swore I was anemic, but every time I got my blood work back, the lab measures that are typically looked at for anemia, serum iron and ferritin, looked great, which was so frustrating! Little did I know, serum iron and ferritin are only 1 piece to the anemia puzzle, there are many clues you can find on your bloodwork where you can find hidden anemias.
But what is anemia? We know it makes us tired, we know it makes us slower, and we know it’s important to avoid it. But why?
Simply put, it’s oxygen deficiency. It happens when our body doesn't have enough hemoglobin or red blood cells, reducing our oxygen carrying capacity. We all know oxygen is important, we literally couldn’t survive without it. But what does it actually do?
Oxygen is the fuel that allows our cells to produce energy from the food we eat. No oxygen = No energy. It’s a big deal. This lack of energy causes the fatigue and weakness that many of us know all too well, that feeling when you are trying as hard as you can, yet you feel you are moving through water in slow motion.
Next question is, how do you fix it?
Most people here would raise their hand and shout IRON!!
Good answer! But not the whole answer, which I experienced when my serum iron and ferritin looked fine. I’ll explain. Our red blood cells need to a certain size to hold onto oxygen. Not too small, not too big, just right… it’s a Goldilocks value. In order for your red blood cells to be the right size, you need the right nutrients. Any deficiency in these nutrients can cause them to be too small or too big.
Small red blood cells are caused by a deficiency in iron or vitamin B6. The medical term is Microcytic Anemia, ‘Micro’ meaning small. This occurs because iron is necessary to form heme, the protein that holds oxygen in the red blood cell. When a red blood cell loses heme, it becomes smaller and shrinks. Heme is also responsible for buffering the acid out of our body and healthy detoxification.
Your blood work can tell you if your red blood cells are too small. A CBC is a common test your doctor usually always runs, and you will look for a lab value called ‘Mean Corpuscular Volume’ (MCV). When your MVC is lower than 84 fL, your red blood cells are too small and you are compromising your oxygen utilization. You will notice that this number is not the same as the ‘standard’ healthy ranges which is 80 fL, but we use ‘functional’ and ‘athlete’ ranges which strive for optimal health.To differentiate between an iron deficiency or B6 anemia, you can cross check some blood values. Consider an iron deficiency if your ferritin and serum iron are low (for athletes, we like to see ferritin over 50 ng/mL and serum iron between 85-130 ug/dL). Consider a B6 deficiency if your homocysteine is high (anything over 7 umol/L is considered high).
Big red blood cells can be caused by B12 and folate deficiency. The medical term is Macrocytic Anemia or co-factor anemia. ‘Macro’ meaning big, so you have big red blood cells. The lack of B12 and folate prevent your red blood cells from maturing. Immature blood cells are like big babies, they don’t quite have the coordination to hold onto oxygen.
If your MCV is above 90 fL, your red blood cells are too big. If your MCV is high, try supplementing with a high quality B12 such as methycolbalamin, hydroxycolbalamin, or adensylcolbalamin.
If both your MCV and MCH (mean Corpuscular Hemoglobin) are high, supplement with B12 and folate. High MCH is anything above 31.9 pg (for our ‘functional ranges’). For folate supplementation, it’s always best to avoid the inactive form, folic acid. This is because it’s suspected that 50% of the population carries a gene mutation that prevents them from effectively activating folic acid to its active form. We recommend saving your body some stress, and just take the active forms: Calcium folinate or (6S)-5-methyltetrahydrofolic acid.
This is the type of anemia I had, my blood cells were way too big! Which is why no one caught it and it flew under the radar. Iron deficiency anemia gets all the press, but so should B12 and folate deficiency anemia.
Getting it Just Right
Iron, B12, B6 and folate are only the tip of the iceberg. There are many types of anemia because there are many things that can interfere with the ability to produce enough hemoglobin and red blood cells. Infection, malnutrition from a damaged intestinal tract, nutrient deficiencies, heavy monthly menstrual flow, certain pharmaceutical drugs (including birth control), genetically inherited conditions, the increased demands of pregnancy, NSAIDS (like ibuprofen and aspirin), bone marrow and stem cell disorders, induced stomach inflammation, heavy metal poisoning, snake and spider venom, and even the impact of running can burst your red blood cells (a condition called hemolytic anemia). Yikes, that sounds like a lot!! But don’t be overwhelmed, the goal at the end of the day is to find and remove these stressors so our red blood cells can build, mature, and hold oxygen properly.
So how do you identify if something is off? Blood work is a good start, and looking at your genetic data is a bonus. Stay tuned as we will go more in depth on what blood markers and genetic markers to look for. A good start is checking your MCV and MCH. Also note that dehydration can falsely affect these measures, another reason to stay on top of hydration - so you can read your blood values accurately.
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