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Iron Deficiency Anaemia in Athletes with Kate Smyth

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Iron Deficiency Anaemia in Athletes with Kate Smyth

What do we do when exercise that should be making us healthy and strong seems only to be making us sicker?  

Iron deficiency anaemia is one of those conditions that can be caused by frequent and strenuous excercise, which is why it is extremely common in athletes. Despite it’s prevalence, however, it can sometimes be difficult to spot through bloodwork and symptoms along. 

Naturopath Kate Smyth has first hand experience treating this condition in athletes, both as a clinician and from her own journey beginning as a causal runner to Olympic athlete in just eight short years. 

In this episode Kate shares her story, and takes us through the warning signs of iron deficiency anaemia in athletes, the most common causes, and the various treatment options available, particularly when treating elite athletes. 

Covered in this episode

[00:57] Welcoming Kate Smyth
[01:55] Kate discusses her path from runner to Olympian 
[07:29] Putting together an international team of practitioners and coaches
[09:10] High altitude training and the beginning of Kate’s health issues
[14:10] Kate’s path to recovery and the power of visualisation
[18:33] Recounting the various testing Kate went through to get her diagnosis
[20:18] Why is iron deficiency anaemia so prevalent in athletes?
[27:03] Warning signs of iron deficiency anaemia in athletes
[30:30] Pathology markers
[36:28] What the research is saying
[38:37] Chronic consequences of low-grade anaemia
[41:04] Treatment options
[49:19] Finding appropriate naturopathic treatments while remaining compliant with substance restrictions
[50:22] Thanking Kate and closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us on the line today is Kate Smyth, who developed her passion for natural medicine during her career as an elite endurance athlete competing in the Women's Marathon for Australia at the Olympic and Commonwealth Games, and becoming one of the all-time fastest women in Australia with a personal best time of 2 hours, 28 minutes. 

Her journey was not without challenges, and she required the assistance of many holistic health practitioners from around the world to overcome her own health challenges and to progress from fun runner to Olympian in just eight years.

During her sporting career, Kate identified the need for a holistic service tailored to the unique requirements for athletes, and set about creating an innovative sports naturopathy service. Kate, welcome to FX Medicine. How are you?

Kate: I'm very well. Thank you. Thanks for asking, Andrew.

Andrew: Thanks so much for taking time out of your busy schedule to join us. Before we get into our topic of the day, anaemia in elite athletes or athletes, can we go back a little bit into your history? Because it's actually quite amazing. You went from a fun runner to an Olympian in just eight years. You weren't groomed for this. 

Kate: No.

Andrew: How the heck did you accomplish that?

Kate: With a lot of stupidity or dog-headedness, as most people would say. But my journey really started when I'd been traveling overseas and eating way too many pastries and carbs in Italy, and literally put on about 20 kilos. And when I came back to Australia, I felt very uncomfortable in my own body, and I decided I wanted to get fit again. 

I'd always loved my sport ever since I was a youngster, and I'd always done lots of different sports — team sports, and running, and a whole range of things. But I was definitely not a junior superstar or anything like that.

And I just decided that I wanted to lose a bit of weight, and I set myself two targets for the year ahead. One of them was to finish a marathon without walking. I didn't care how long it took me. And the other one was to overcome my fear of heights. 

Andrew: Right.

Kate: And with that one, I did a bungee jump 110 metres and that definitely overcame my fear of heights. So now I love heights.

But the marathon journey really started when I ran Canberra for the first time. And I did finish, and I did it without walking. And I felt like I really loved it. I loved the experience. I love the atmosphere of running. I loved everyone, the camaraderie. 

And at the end, Robert de Castella was there as a spokesperson, and he was just signing autographs. And I went up to Deeks and I said, “I've just finished my first marathon. I'd really like to... How do you become a good marathoner? It seems like a lot of hard work.” 

And he said, “Well, probably good to actually train properly, get a coach and just take it one step at a time, literally.” Because at that stage, I really did need… I didn't have the gear. I didn't even have a pair of running shorts. I borrowed my brother's boxers. I had no idea. I didn't run more than 30 kilometres in an entire week when a marathon is 42 kilometres in one sitting. So, I was so underprepared, but I loved it.

And I did go back to Melbourne and started to train with a group. The coach just made it so much fun that I wanted to go for the social aspect more than anything else. And the fitness was, you know, absolute bonus. And I just started to really enjoy it, and I started to gradually get faster and faster. 

But it wasn't really until the Olympics set in Sydney that my Olympic dream was born. And that really happened because I was sitting in the stadium just as a spectator, and I watched the women come in from all different countries. And Naoko Takahashi won that year in, I think, 2 hours, 24 minutes from Japan. And she was just the most beautiful, gracious… She was like my ideal winner or someone...you know, a sports person that I could really look up to. 

Andrew: Yeah.

Kate: And she totally revolutionised women's running in Japan. It had been such a male-dominant sport. And she changed so many things for her own countrywomen, but for women all around the world.

And as I sat down and I watched her come in to the stadium and cross the line, the hair literally stood up on the back of my neck. And it was like a light bulb just went off in my head, and it was like, “That's your path. That's what you've got to do.” You know, I didn't have any of the background to say it was possible, but in my heart, I guess I just went “That’s it. That’s it.” So, from that moment onwards, that was in 2000 and then I ran in the Olympics in 2008.

That journey of eight years was the most incredible journey and life experience that I could have ever imagined. The people that I met, the countries that I traveled to, the competitions that I went in, the learning experiences about myself, the inner strength that you develop, the mindset, the learning from a health perspective, because it was definitely not smooth sailing for me by any means. 

Andrew: Right.

Kate: And by also developing, I guess whether it was courage or out of desperation that I started to look outside mainstream sports medicine for answers and for support, that could make me a better balanced athlete and to overcome some of the health challenges that I had personally along the way.

Andrew: Now, you were also exposed to international coaches as well.

Kate: Yes. I was coached by a coach based in New Zealand. So, the training method was quite different under the Lydiard or New Zealand-based system to the Australian system. 

Andrew: Right.

Kate: But I tried a number of different things before, you know... And I don't think any...there's a right or wrong way of doing it. It was just I like to experiment and use myself as a guinea pig to see whether I could get the edge and get the most out of myself.

Andrew: Now, if you weren't part of the Australian Institute of Sport, like, a funded body, how did you fund this? All yourself?

Kate: All myself, yes. I worked full-time for the majority of my career for the first six years. And I used to just save up all my annual leave and save up my money to fund my sport.

Andrew: Wow.

Kate: And that was just the only pathway that was open to me because I was in my late 20s, early 30s when I started to run well. And by then, I wasn't deemed as development material. So, I didn't qualify for anything. I applied six years straight to some institutes and I got knocked back every single time. 

Andrew: Right.

Kate: Even though I was progressing, it's just a bit of a framework that a lot of our institutes worked through. So, I had to really learn for myself, and I had to pull the team together of healthcare practitioners and coaches and everybody else that you need to keep you grounded and balanced. I had to handpick all of them to come in and form my own team.

Andrew: Now, tell us a little bit about your exposure, I think, was it high altitude exposure in America? And you experienced a health issue, because that's important to what we'll be discussing today.

Kate: Yeah, sure. So, I used to go to Boulder in Colorado and I used to go there for our winter to Bear Summit. It's to prepare me usually for an October race in either Europe or America. And so, I was at high altitude. I used to fly into Denver which is already a mile high. And then I used to go further up into the Rockies to do additional training up there. So, I was exposed to hypoxia. 

We do have a quasi-form of altitude training up at Falls Creek that we do generally...runners do or endurance runners do if they're Australian-based over the summer. But that's not true altitude. That doesn't really… I tested, before and after, my hematocrit, it really didn't change. So, it wasn't true altitude training. 

But I certainly did experience the pros and cons of doing that in terms of too little or, more importantly, too much and not being prepared for that in terms of what can happen if you over-train. And if you're not prepared and balanced certainly from an iron storage perspective, you can bury yourself fairly easily as well. 

Andrew: Right.

Kate: Yeah.

Andrew: But you also suffered some issues as well.

Kate: Health issues. Absolutely. So, I did a stint down at the AIS where I was invited to be a subject on a study in the altitude chamber. So, it saves me having to go overseas at times. 

Andrew: Yeah. Yes.

Kate: And one morning, the researchers came to me and said, “Are you drinking?” And I said, “No, absolutely not.” And they said, “Well, your liver enzyme levels are through the roof. There's something... You're not well. You need to go home.” And so, my arrangement there was promptly terminated. I had to go back home to Melbourne and I had to find out what was going on. Because you really get so used to being tired when you're running up to 200 kilometres a week as well as extra training sessions, you’re used to that tiredness and fatigue.

So, I just couldn't really pinpoint what was going on. And I went to quite a few mainstream practitioners and sports medicine practitioners. And they could tell a bit of information, but really couldn't pinpoint exactly what was going on. I was getting quite desperate because I really wanted to race again. I had another event planned for later on in the year. 

And that's when I decided to seek some help from an integrated GP who also practiced naturopathy. And it was through his investigations that were very thorough that we identified that I did have Coeliac, I did have insulin resistance, I did have liver damage, and very high enzymes there because I was given an anti-inflammatory drug that has been withdrawn from the marketplace.

Andrew: Did you have diagnosed non-alcoholic fatty liver disease, NAFLD?

Kate: No, I didn't have that. I don't think that was possibly really suspected just because there's not much fat in an endurance athlete anyway. We're not atypical. But it was definitely, yeah, the liver. There's something not right with the liver. Let's just check. But yeah, it became apparent once my history was taken down in terms of, “Ah, that particular drug has just been withdrawn for a whole range of complications.” So, as soon as I came off that, things tended to settle down a bit.

Andrew: Kate, just going back to your early time, just for a second. In your younger years, were you healthy and well, and had heaps of energy back then? You had no issues with sports and normal periods, for instance, and all of that sort of thing?

Kate: When I was younger, I guess, I certainly had very light periods because I was very active. And I did play lots and lots of different sports. I had more totally unrelated symptoms. I had bronchial asthma, was my greatest challenge and random things, ovarian cysts and just random things. Not so much gut-related issues or anaemia, by any means.

Andrew: No skin itching or anything like that?

Kate: No. Nothing.

Andrew: Nothing that would have given any GP in your earlier years a signal to go, “We might investigate Coeliac disease.”

Kate: No.

Andrew: Okay. So, forgive me. So, we've gone back in history and back to the future. Now, we're at the stage where you've been diagnosed with Coeliac. How did that translate with the AIS? Was that just too late?

Kate: Yes, by then I was detached from the study. So I wasn’t on a scholarship with the AIS, I was literally a lab rat for them. 

Andrew: Right.

Kate: So it didn’t really change anything there. It just meant for me, that in my mind, that a holistic approach was just what I wanted and needed to embrace. So that I could get back to being able to be within a stone’s throw of qualifying for the Olympics.

Because at that stage, I was way off qualifying. Way off qualifying and I only had a six-month window before qualification would be…

Andrew: Cut off.

Kate: …ended. You only have a short window for qualification.

Andrew: Yeah.

Kate: So I went through literally three months of heavy detox… Well, heavy as in chelation detox, and heavy as in I only ate whole foods. I didn’t have anything out of a packet. Absolutely. It was really a great diet, but you know, it was back to basics for three months. And I could only walk. I wasn't allowed to run.

Andrew: Right.

Kate: So, that was about August/September when that started, that process. And then by December, I was allowed to start jogging again. I couldn't get my money back on the entry that I had for a race in Germany. So, I decided to still go to Europe and go on a get-well holiday. So, I went on the get-well holiday and just started training very slowly and gently again.

And then January, I rebounded so well. Once I was nutritionally repleted, I was balanced, I was healthy, I was sleeping well, I was recovering well. I wasn't catabolic anymore, you know, all those things that can be reversed through good nutrition and a lot of patience. To the point where in April, I went over to Japan to run my last chance to qualify for the Olympics. 

And I had to...I literally had to blow the qualifying time out of the water for me to get picked, because the race before that was a disaster in the Commonwealth Games where I'd collapsed from heatstroke. 

Andrew: Oh.

Kate: And you often only get selected based on your past performances and time. I had poor past performance, and I was not even within the qualifying time. I had to really give it everything.

And that race in Japan was just...it was incredible because I'd done so much work when I was lying on my bed not able to run. I did so much work on my mindset on visualisation, on the whole feeling and journey of what a beautiful race would be like, that on race day, it unfolded. 

Andrew: Wow.

Kate: It unfolded just that way I dreamt it would, like, literally.

Andrew: That is such a powerful message.

Kate: It was amazing. It just showed me, oh my goodness, this is possible. Because I had to run under 2:32. And at the time, I'd only run over 2:33. And I knew I had to chunk it up, as in I had to really go for broke and really run the best time that I possibly could. 

And I thought 2:28 was about right. And I stuck 2:28. I wrote it down and I stuck it on everything. I stuck it on my toilet. I stuck on my driver's wheel. I had it in my diary. On my watch, it would go off at 2:28 in the afternoon. Like, the 21 days before the race. And I meditated on 2:28 and I used to just go through the visualisation of crossing on the line.

You know what happened? When I went into that stadium in Japan, I looked up, and it was 2:28. 

Andrew: Wow.

Kate: And I'd ended up qualifying as the fastest female runner that year in 2008. So, they had to take me on the team.

Andrew: Just a quick question before we get into our subject, which is anaemia. And I just want to ask about, what testing was done by your integrative GP before and after? What sort of tests were looked at apart from the standard Coeliac test?

Kate: Look, he ran... It was a long time ago now to remember all the tests. But he did run just a lot of tests. 

Andrew: Right.

Kate: Yeah. You know, of course, he did the general pathology screening. But he went the extra steps, you know. He looked at my insulin. He looked at the broader markers, the things I didn't do, a stool test. I did do a serology test. I did do a bowel biopsy…

Andrew: Yes.

Kate: We… I don’t think, no, we didn't even do the HLA. We didn't do the genetic testing. But that was... You know, the serology was so off the scale along with the liver enzymes, the bowel biopsy. That was, you know, pretty conclusive.

Andrew: You were also shown to be iron deficient at the beginning. So, did that raise during your treatment?

Kate: Yes, totally, because we worked through inflammation as well. And, yes, absolutely. But up until that point in time, I had had - I think I've lost count - how many iron infusions? It was just the standard. "Oh, she's getting low. We'll give another iron infusion.” This is not truly integrated. This is the other pathway. 

Andrew: Yeah, yeah.

Kate: So, I would have multiple iron infusions even in a year just to keep me at decent levels. Not once was it suspected that I would have Coeliac.

Andrew: Yeah. Now, why is iron deficiency anaemia so prevalent in athletes, not just the Coeliacs, but all athletes?

Kate: Yeah. You know, that's a great question. And it's a combination of factors. There is definitely a prevalence for female athletes, or athletes in general, to be switching to more plant-based. So the intake side is definitely dropping, but the demand that athletes, I don't think, is probably as well recognised as it could be in that. I would say, depending on the training, they can need up to 70% higher than what a normal RDI is for general population. They need a lot more. 

And then there's a whole lot of other factors. There's things like the haemolytic breakdown both through foot strike. But we kind of know now that that's more about exertion, haemolysis, because we see it also in non-weight bearing sports. Things like rowing and weightlifting and swimming. But that's more to do with the compression of the blood vessels through the muscle contraction.

Andrew: So, a physical stressor on the red blood cells.

Kate: Yes. Yes. Yes. We used to think heel strike was a big deal in terms of blood loss in athletes. We now know it's not a huge contributor, but it is a contributor of some kind. Because we also know that now there's a mechanism for recycling. Once things are broken down, our body has a great way of capturing all that excess iron and recycling it. So, yes, we're destroying the red blood cells, but we're not necessarily always losing the iron.

Andrew: Upon heel strike.

Kate: Heel strike, physical heel strike, bashing on the ground. Yes, it breaks it up. Mechanical breakdown.

Andrew: So, therefore, even running style could affect your haemodynamics.

Kate: Absolutely. Yes, absolutely.

Andrew: Wow.

Kate: And also, you know, if runners are running in cities and they're running a lot on cement and very hard surfaces, that will increase the likelihood of that happening. Yeah. 

But as I said, the overall impact is there, but it's not the major contributing thing.

One of the big losses that we find is haematuria. It's actually through the kidneys because there's actually... When skeletal muscles are really engaged, there's more constriction of the renal artery. So, there's a bit of nephron damage that occurs just microscopically. And then there's also the glomerular capillaries that expand, and they allow the red blood cells to pass through. 

And you've also got to remember, in sports, when athletes are really pushing themselves and there's a lot more lactic acidosis, even just transient, post-exercise, that will also increase the permeability, the glomerular permeability. 

Andrew: Yeah, yeah.

Kate: So, often, after races or heavy sessions, athletes will...could have rusty urine. That's a classic case. You know, post-marathon, rusty urine. And that resolves after a couple of days. So, it is transient. But if athletes are doing back-to-back endurance hours and hours, it accumulates. Definitely accumulates.

The other thing that we find is the gastrointestinal bleeding. And it may be a occult, but 20% of athletes and 30% of marathoners, especially the endurance, the ultramarathoners have that microtrauma to the GIT lining. And we've also got... You know, the sympathetic nervous system is so engaged or heightened when people are doing physical activity at a high level that there's the ischaemic damage to the lining. And, you know, you've also got to think of... 

There’s also, you know, the caecal slap syndrome. I'm not sure if you're familiar with that.

Andrew: No.

Kate: It's just physical mechanical trauma due to acceleration and deceleration. So, you may see that in players like team players that are football players and soccer players. They're changing direction. Basketball, netball. 

Andrew: Netball.

Kate: You know, that's also at play there. And then we lose it through sweating as well. That's definitely a player. Altitude training, as we've touched on before, you know, that definitely increases the demand for iron.

Athletes, because of that sympathetic dominance, and cortisol going up. We've got the response on reduced stomach acid. So, that's got an impact on the absorption, obviously. 

And then you've got the response where there's an acute inflammatory response post-exercise. That's really driven through cytokines, interleukin-6 and tumor necrosis factor. And that really drives or changes hepcidin. And that tends to happen when athletes are exercising at 65% of their AcuMax. So, the upper end, you know, of threshold.

Andrew: Right.

Kate: Yeah. And it reaches maximum levels, and you sort of get up to the 90%, 95%. So, race end should get more of that response.

Andrew: We've seen in a few marathons, particularly on a hot day, that sort of thing, but not just that, the mechanisms by which athletes suffer rhabdomyolysis. You know, you've got nephron damage. You've got direct muscle damage from the muscle working during the load, but also the pounding of the heel, the tension around the renal arteries…that’s amazing.

Kate: And then you think of senior athletes, our lovely Master’s athletes, that are still going, there is increased kidney function… sorry, kidney issues…

Andrew: Kidney issues, yes.

Kate: That can also be exacerbated because of long term use of anti-inflammatories and all the rest of it to keep them going.

Andrew: Yes, of course.

Kate: Yeah, it definitely does exist. And athletes sometimes, in some modalities there’s a bit of a “camel” mentality. You know, “I’m not going to drink because it looks… I don’t want to stop to drink. It chews up time.”

Andrew: Oh, okay. Right.

Kate: So you can just imagine the impact on the poor renal system.

Andrew: Yeah, absolutely. With regards to who may be at risk of iron deficiency anaemia, what are some of the key things we really need to look out for? The early warning signs.

Kate: Yeah, look, a lot of them are common to the general population. Often athletes will complain that their perceived exertion has changed. So they’ll feel normal in their day-to-day lives, but it’s not until they train or race that they feel they don’t have their “second gear” anymore. They’ll get more shortness of breath during exercise, so basically their VO2 Max is being reduced.

Andrew: Yes.

Kate: So they can go for an easy jog, they can go through a recovery session, but it’s when they push themselves that they really notice it. 

Andrew: Right.

Kate: You can definitely see more frequent infections of any kind. And then there’s the general signs. More weakness. They’ll get, possibly, more restless legs. Poor recovery. You may get headaches. You will get some that will have cravings for things like ice, but it’s very rare that I see that in clinical practice. 

I see, more likely, the high fatigue/low energy, the poor adaptation if they go to altitude, the reduced ability to thermoregulate. Their generally a bit more irritable, not as motivated, a bit teary… Yeah, those are the general things.

And often it can creep up. So they can be training really well, and then they’ll go out to a major competition and they run flat.

Andrew: Right.

Kate: And they have no understanding of what’s just happened to them.

Andrew: And how would you differentially diagnose that from overtraining syndrome?

Kate: Well… Yeah, you really do need to take a good history of exactly what their workload has been like, whether they’ve taken breaks over certain periods of time. And in certain codes it’s thought there’s a certain level of tolerance.

But pathology is obviously what we look for. Because you’re right, a lot of these signs and symptoms can be, you know, a bit of both.

Andrew: Yeah.

Kate: Yeah. Definitely.

Andrew: Okay.

Kate: And you’ll get the random ones. The way I always used to always tell that my iron was going down, both iron and B12, was my feet used to start stinging. They just hurt.

Andrew: Oh, right. Okay. So this is…

Kate: I did. And I got that before I would get the fatigue or the change in heart rate. You know, heart rate tends to go up and the blood pressure tends to go down. So a lot of athletes are addicted to their Garmins, you know, giving them feed back all the time and they go, “Oh, I don’t feel sick, why is my heart rate about?” And that’s another good sign.

Andrew: But are they trained? Are they trained to look for these symptoms and go, “Hey coach, listen. Look at this.”

Kate: No. Coaches will generally, if a heart rate is elevated, they will usually think, “Oh, that might be more to do with an underlying infection.” So, their general thought, you know, might suggest they go to a better GP or someone for a general blood checkup. But when that comes back negative, they're just thinking, “Oh, maybe you just need a break from training.”

Andrew: Right. Okay. And when you're looking for pathology of anaemia, don't just do iron, you were talking about B12 as well. What about things like ferritin, total iron-binding capacity, things like that?

Kate: Oh. Gosh, yes. I think there's so many pathology markers that really give us some good clues both in terms of giving us an idea of the stage of iron deficiency before it hits anaemia and what else is going on. You know, you think of all the factors that can affect haemoglobin alone, and there are so many things that we've got access to that we can check and we should look at. Transferrin, of course, you want to look at that because that's the carrier, that's the taxi or the tram that's carrying the iron around. 

But we've got to also... When we look at the markers, we've kind of got to keep in mind that inflammation response as well. And the way that we...or the timing of our testing for athletes can be a bit tricky.

Andrew: Yeah.

Kate: Very tricky. But, of course, we'd like to look at ferritin as the storage. And it gets a little bit interesting. This is where I think integrated medicine differs, in that the general ranges for ferritin are below 30 and then there's possibly an iron storage issue. But now, the research is really showing that, really, athletes need to be more around 50 to 65. 

Andrew: Right.

Kate: Below that, performance can be affected, and the way they recover can be affected. And some of this evidence, this great evidence, has actually come out of our own AIS down in Canberra. They've done quite a few studies and the body of evidence is definitely building in terms of optimal ferritin for athletes. But we've still got a wee way to go in terms of really better understanding that. 

But definitely, I see it in athletes. It's like the balloon is deflating when it starts going under 50. But there are anomalies because athletes do adapt. And I've had elite athlete that has only had stores of ferritin of 12, and they had still been able to compete at an international level well, and felt okay.

Andrew: Wow.

Kate: Yeah. So it really is individual. 

Andrew: Yeah.

Kate: And I think we absolutely have to take that into account. So, definitely looking at ferritin, definitely looking for other signs and symptoms. Red cell distribution width, is it more B12 or more iron related? Globulin, is that high or low? Because that’ll be low along with iron as well. 

Is there any suspicion that there might be parasites? Do we need to do gut stool testing? Is there any possibility that this person might have high copper, for whatever reason? 

I don’t think that we can just think “Because they’re athletes that it has to do just with their sport,” because the number of athletes that I have that have got other factors other than their training that’s contributing to their iron deficiency is really, really high. Really high.

Andrew: They tend to be people as well as athletes.

Kate: Oh, totally. Totally. And even things… We have to check CRP. If you’re not checking CRP, that’s one of the main drivers. We’ve got to check that and it’s got to be in the same blood draw.

Andrew: Right.

Kate: But even things like vitamin D. And vitamin D is a tricky one because in really lean, fit athletes, they don’t have fat stores, or they have very little. Their body fat is quite low.

Andrew: Yes.

Kate: And vitamin D is stored in fat, as well. So you can’t help but think “Okay.” And we know that there’s this relationship between vitamin D and iron. They both need each other, they both influence each other. We may think from the immune perspective with vitamin D but we’ve also just got to remember that it also has an influence over some of the inflammatory cytokines and hepcidin, again. 

And then you’ve got to think back the other way in terms of iron helping vitamin D as well, through synthesis and conversion. Because of all those amazing cytochrome enzymes, the P450s that are all haem dependent. I could go on and on about the parameters.

Andrew: What about confounders, like those anaemias which aren't responsive to iron, but are responsive to other things?

Kate: Yeah. This is where we really, as you just pointed out before, we absolutely need to look at this person in front of us as a human being first and foremost before an athlete. Because it is really prevalent to see the malabsorption. Definitely, even just gut inflammation will impact. Definitely checking for any intolerances, hypochlorhydria is really prevalent, as I touched on before. Your B12, your B9, B6, they've all got such an influence. 

If we do a complete history or if we do a thorough analysis, especially gut health, there'll be other clues that suggest, ‘"Oh, there's mucus in the stool. Oh, they may have an itchy backside. I really think we need to do that stool test as well.”

Andrew: What research specifically looks at the needs of female athletes?

Kate: Yeah. So, this body of evidence is really growing. There's heaps on sports and there's heaps on the crossover between sports and anaemia. You know, 16,000 in there and 4,000 just from articles in terms of publishing between 2015. And we are seeing more large analysis coming through. 

There's a great meta-analysis done in 2014 that was published in the British Journal of Sports Medicine. That covers 17 studies. But although it wasn't published as specific for female, there was only, I think, 2 or 3 of the 17 studies that had males in them. The rest were all female. And that was really looking at iron needs in the female athlete, but also the unique issues compared to males. Because we didn't even touch on before the fact that having menstrual bleeding can actually impact on women as well.

Andrew: Yes.

Kate: And there's another great study that was published in 2016. It was actually conducted on London Marathon participants, and they studied 1,800 women then. And over 35...well, it varied a little bit depending whether they were elite or recreational runners. But over 35% of the marathoners had heavy menstrual bleeding. And 38% of them, of the recreational ones, recreational athletes had a history of anaemia. But 52% of the elite athletes have a history of anaemia.

Andrew: Right.

Kate: So, I think we are moving in a really positive direction. A lot of the research is coming out of Europe, but our own AIS researches are actually doing some really good work here, too. And I think we'll probably, as women's sport, it has just taken off in all...you know, all sporting codes. I think we'll see a lot more funding going into this area, which is really exciting.

Andrew: Absolutely. Kate, we need to talk about chronic consequences of low-grade anaemia or just insufficiency of iron and, I guess, general nutrition, but especially iron in athletes. 

What are the issues here? What are we running into? You mentioned before infections and things like that. So, are we talking just coughs and colds or more chronic type things?

Kate: Look. It comes varied...in very... You know, it can be infections in the gut. It can be things like thrush. It can be upper respiratory. Upper respiratory is probably the more common ones that I've personally seen in clinical practice. But, you know, infections of any kind., and recovery, especially recovery from infection. It will just take a lot longer because a lot of athletes want to jump back into training a little bit too hastily, as well. But we also see things, like longer-term thyroid issues. We can see arrhythmias. And then longer-term, enlarged hearts. And there are...

Andrew: So, remodeling.

Kate: Yeah. And heart complications further down the track. And I think also, athletes, as they go into pregnancy, it's a major issue. And a lot of elite athletes like to train through pregnancy. So, it's a bit of a red light that goes off if an elite athlete says, “I want to fall pregnant, and I've had a history of anaemia." I say, “Well, we absolutely need to be onto this and be checking you regularly.” Yeah.

But then, you know, there's other issues that are touched on with that vitamin D linked with iron and osteoarthritis and bone issues. It's not just about the vitamin D. It's also because of collagen. Collagen, type 1 collagen, that can constitute about 90% of total bone protein. And the iron’s required in terms of its enzyme activity for that collagen synthesis. So, we're affecting it that way as well as through the vitamin D.

Andrew: So, when we're looking at treatment options, take us through some of the pros and cons of those available to the athlete, I guess, particularly.

Kate: Sure. So, we've got supplementation and iron infusions are the most common. And the injections have sort of gone, the muscular injections I'm referring to, have gone out of favour because of their bruising and a GP needed a bit of a skill to do that with the weave technique. So, we're really looking at the two main options now. 

And the supplementation, yes, will take possibly… Well, it will take longer to bring the athlete’s levels back up. But with the right formula, I find that you get good compliance and limited side effects with the right choice for them in terms of formula. 

But of course, you can get constipation. That's pretty common on some formulas. Others may in fact get nausea or even sort of almost GORD-like symptoms, a bit of heartburn and other gastric discomforts. But I tend to find constipation is the main drawback as per…

Andrew: And the lovely tarry stool.

Kate: Yeah. And then we've got the IV. And the IV has become particularly prevalent and popular, especially for athletes because they do want to get back out there and recover as quickly as possible. A lot of them’ve got timelines, you know, a competition in six weeks, for example. They need to be right for that. So, it will raise, obviously, the iron much more quickly. But it does so with a very large amount of iron going in.

So, generally, we know that we can take on board about 600 milligrams of macrophage iron at once. And we're seeing IVs in a 70-kilogram person, for example, going up to 2,000 milligrams. Generally, the recommendation is between 500 to 1,000 because, really, there isn't a huge amount of evidence to go over 1,000, but it does happen. 

Andrew: Yeah.

Kate: But I think the issue then is what's happening to that free iron, what's happening with the oxidative stress? And perhaps once or twice, maybe it's transient. But when athletes are having multiple, multiple experiences of iron overload, we have to kind of think of, “Well, what's the accumulative effect of this?”

And I think this is where we could really do with some more research. We know about general iron overload, but we don't really have a clear idea of, “Okay. So, how many infusions can one person have before they'll have symptoms of degenerative bone issues?” Because it does…

Andrew: Heart damage, kidney damage, brain damage.

Kate: Yes. It damages so many tissues in the body. We've got to think of liver, heart.

Andrew: Yeah. It's a forced haemochromatosis. It's not hereditary in this instance. So, no research in athletes at this level.

Kate: Not in terms of specific number of iron infusions. Yeah. 

Andrew: Got you.

Kate: There’s plenty in general on female athletes and anaemia and using IV therapy. It's just there's not… I don't believe that we've got a decent body of evidence to suggest how much is too much.

Andrew: So, now that you've got your training behind your belt, what sort of support do you offer your female athletes who you're looking after?

Kate: So, what I try to do is work on the underlying cause so that they don't need repetitive iron infusions. 

Andrew: Yeah.

Kate: I work on sustaining their iron rather than the other...you know, going down the other path. And sure, things like N-acetyl cysteine and other antioxidants, I've used it out there. But, again, the evidence...there is supportive evidence for that, but just not enough to say “You need this dosage for this kind of level of iron infusion.” 

So, the way I like to tackle it is to really educate the patient in terms of, and not put them in the situation where they have a dependence on them in the first place.

Andrew: Yeah.

Kate: Solve the underlying driver.

Andrew: Yeah. So when we’re dealing with Coeliacs, I mean, obviously gluten avoidance…

Kate: Yes.

Andrew: …but what about, once an athlete presents to you with gut issues, you know, they’ve got a precipitously low iron, or stuff like that. What sort of support do you engage in to say “Okay, we need to heal you first.” Do you take them through the same sort of journey that you went though: vastly reduce their exercise down to a minimum, you nourish their body back up, you heal the issue that was causing the iron deficiency anaemia? Is it the same sort of journey? 

Kate: Yes and no. And that totally depends on their timeframe.

Andrew: Got you.

Kate: If they’re racing at world championship level in six weeks, they will probably need to go through the IV route. 

Andrew: Right.

Kate: But at the same time, we need to start all the foundational stuff. So absolutely gut health has got to be a number one priority, along with supporting their inflammation and dampening that down. Because there’s systemic inflammation in elite athletes, continuously. 

But there’s a lot of other things that we can do to support athletes while they’re in recovery phase if they’re not working towards a major event. And it’s a lot to do with balancing their training load. You never tell an athlete to rest, that is such a dirty word. You don’t say, “Sit on the couch and do nothing for 8 weeks,” while they recover. Absolutely a no-go.

So you have to keep them moving. You have to have to keep their cardiovascular systems active and fit so they can maintain that level. We’ll reduce the loss, I have to say, reduce the losses in that area. But you do need to work with their support networks. Work with their coaches and their strength trainers to reduce the load.

And generally, I suggest around 40% to 50%, depending on how far gone they are. If it's just early stages of iron deficiency, then drop it back by 30%. But it's also dependent on how they feel. If they're feeling flat and crap, they're just going to lose a whole lot of confidence by training like that.

Andrew: Got you. Yeah.

Kate: Switching them onto other fun activities and still using their cardiovascular system, but not so weight-bearing and so taxing on their overall usage of iron anyway or their loss of iron can be really beneficial. 

Things like if they're a weight-bearing athlete like a runner or a triathlete, for example, getting them in the pool and doing water running, doing a bit more swimming, doing hypoxic work is brilliant for lung function. Yeah, like what the divers do. You can switch that up. You know, again, athletes, they do that all the time. Even cycling is great because you're not having the same level of force.

So, definitely, reducing the intensity as well. So their sessions come back in length and in intensity. And there are so many other things that you can work on while they're recovering. You know, supporting them with their mental preparation, encouraging them to work on their sympathetic nervous system and rebalancing that with their parasympathetic. The core strength and flexibility and so many things you can do.

Andrew: One last quick question before we go, Kate. And that is, how do you manage all of this from a naturopathic perspective with regards to ASADA and WADA?

Kate: So, when we're giving supplements to athletes, we always need to check. And there are products now that are what we call “HASTA-tested,” which is basically a company, an offshoot basically that's independent of ASADA or WADA that will do testing on supplementation. And you need to look under a specific sporting code to see whether a particular supplement is okay. 

So, when I work with elites that I know are under testing, I just check. I always check and I try to source products that are through approval. Or I'll do it old-school and I’ll go through absolutely every single ingredient and then check it. 

Andrew: Right.

Kate: And I always make sure that they're Australian-based so that we don't have problems with extra insidious ingredients slipping in there.

Andrew: Kate, thank you so much. There's obviously so much more to cover. Thank you so much, though, for taking us through at least some of the issues, particularly your story. 

I've got to say, you're a bit of a champion here. That's no mean feat to come from a fun runner to an Olympian in eight years. Well done to you. 

Kate: Thank you.

Andrew: And well done to you for supporting your patients from your journey. So, thanks so much for joining us on FX Medicine today.

Kate: Thanks, Andrew.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.


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