anaemia quiz Archives - Athletes Sanctuary

Your Iron is low. But That's Not the Problem

athletesanctuary — Wed, 15 Jul 2026 05:57:18 +0000

You've been told your iron is "a bit low" and handed a supplement. So you take it. Weeks pass. Nothing really changes. That is probably because there is a whole lot more to your iron status than what your pathology tests are telling you!

Sound familiar? If it does, there's a good chance the real problem is sitting below the surface.

Iron deficiency is one of the most common nutritional issues we see in athletes across all sports, all genders and all levels of competition.¹ But iron itself is rarely the whole story. Like an iceberg, what shows up on a blood test is only the visible tip.

Below the surface lies a deeper set of questions: why is iron low? What is making it hard to absorb, store or use? Until those questions are answered, supplementation is often little more than filling a bucket with a hole still in it.

Here are five of the most common myths we encounter and what the research actually tells us.

Myth 1: "I just need to eat more iron-rich foods"

Diet absolutely matters. But if the issue is absorption rather than intake, adding more steak or spinach to your plate will not move the needle. Iron requires a highly acidic environment to be absorbed in the small intestine.

Low stomach acid (hypochlorhydria), gut dysbiosis, intestinal parasites such as Giardia or H. pylori, coeliac disease, or long-term stress can all quietly undermine your ability to absorb the iron you eat. Identifying and addressing the root cause, not just the dietary source, is where recovery begins.²

Myth 2: "If I'm not anaemic, my iron is fine"

Anaemia is the end stage of iron deficiency, not the beginning. Long before haemoglobin drops, falling ferritin levels begin to impair oxygen transport, muscle metabolism and cognitive function. Research confirms that endurance performance can decline by 3–4% in iron-deficient but non-anaemic female athletes, with improvements of 20% observed after supplementation.³

For endurance athletes in particular, the evidence now supports a ferritin threshold of at least 50 µg/L well above the 30 µg/L commonly listed as the lower reference on a standard blood panel.⁴

Myth 3: "More iron supplementation is always better"

This one can actually backfire. A single large oral dose of iron triggers a spike in hepcidin, the hormone that regulates iron absorption which suppresses uptake from the very next dose for up to 24–48 hours.⁵ More frequent, higher doses do not mean more iron reaches your cells. If imbalances already exist between iron, zinc and copper, more iron can actually make things worse.

Current research supports alternate-day supplementation taken in the morning when hepcidin levels are naturally at their lowest, paired with vitamin C, and well away from coffee, calcium and hard training sessions.²,⁵

Myth 4: "My GP says I'm in the normal range, so I'm fine"

Standard laboratory reference ranges are built around the general population, not athletes under high training loads. A ferritin reading that looks acceptable in a sedentary adult may represent a meaningful deficit for a runner clocking 80-kilometre weeks or a swimmer in twice-daily training.

Iron status also shifts with training load, illness, altitude exposure, hormonal cycles and energy availability, meaning a single annual test provides a very incomplete picture.¹,⁶

Aim to test at least twice a year and more often if you are iron deficient, approaching altitude, or increasing training load significantly.

Myth 5: "Iron deficiency is a standalone problem"

This is perhaps the most important myth of all. Iron deficiency in athletes rarely exists in isolation. Relative Energy Deficiency in Sport (REDs), a state of chronically low energy availability is strongly associated with impaired iron status, as the body down-regulates non-essential processes, including nutrient absorption, when fuel is scarce.⁷

Thyroid dysfunction, including subclinical hypothyroidism, is closely linked to both low stomach acid and altered iron metabolism so individuals with iron deficiency can have significantly lower levels of thyroid hormones FT3 and FT4.⁸

Genetics can also provide useful understanding around iron mobilisation and iron requirements as detected in our myDNA Comprehensive Health Report. Underlying infections such as H. pylori or intestinal parasites compete directly with the host for available iron and can make supplementation entirely ineffective until the infection is resolved.²

So, What Should You Do?

Start by asking better questions. Not just "how low is my iron?" but "why is it low, and what is making it hard to correct?"

A thorough investigation, one that looks at a range of markers not just ferritin, paired with an honest conversation about your training load, energy intake, gut health, recovery, calorie intake, mood and stress, is where meaningful answers come from. If you have been supplementing for months without real improvement, that itself is a signal that something below the waterline deserves attention.

Iron deficiency is common, correctable, and often mismanaged. Understanding the full iceberg is the first step toward resolving it properly.

If this resonates let’s chat!

Hepcidin and iron regulation

athletesanctuary — Thu, 17 Feb 2022 14:00:00 +0000

Have you ever heard of hepcidin? It’s worth understanding mainly if you are a female athlete or someone who suffers from iron deficiency anaemia.

Iron is an essential element for many biological processes. Too little iron can have many detrimental effects on your health and sports performance. We have previously discussed the impact iron deficiency and anaemia has on thyroid health and poor immunity. Excess iron can be toxic, so regulating iron levels are vital to a healthy, balanced body.

Hepcidin is an iron-regulating peptide hormone that’s produced in your liver. It works to control the delivery of iron to your blood from food through the lining of the intestines. It is the master regulator in iron metabolism and the balance between iron storage and the absorption better known as iron homeostasis. Hepcidin also tightly influences red blood cell production.

When hepcidin levels are unusually high, it reduces intestinal iron absorption and red blood cell production. Low hepcidin levels stimulate iron absorption, and iron supply to bone marrow and promote hemoglobin and red blood cell production. Iron deficiency is common among female athletes, and is much higher than their male counterparts. It is often cited as being a result of the menstrual cycle during premenopausal years. Depleted iron stores can have many adverse effects, including poor performance, low energy levels, and general well-being.

Some research has shown that active females with compromised iron possess an inherent protective mechanism once iron deficient. This adaptation allows the body to adjust to a reduced iron supply. It is proposed iron depletion may be a combination of exercise-induced losses and hepcidin accumulation.

Running is known to acutely increase hepcidin levels (peaking three hours post-exercise), therefore reducing iron absorption and recycling.

Timing iron supplementation to correlate with low hepcidin levels may enhance absorption and positively impact iron levels in the blood. In practical terms, if you exercise in the morning, you might consider taking your iron supplement straight after you exercise, before hepcidin rises.

Hundreds of athletes have used our handy anaemia quiz to help determine the likely risk of having low iron or anaemia. we encourage you to use this free tool if you have a history of iron deficiency or you are unsure if your iron stores may be declining.

Want to know more? Contact the Athlete Sanctuary to learn how we can support you further. Book an appointment here.

About the Author: Kate Smyth is a Sports naturopath, nutritionist and female-centric running coach. She is the founder of the Athlete Sanctuary- a holistic healthcare clinic for athletes of all levels and sporting codes. Kate has a thirst for knowledge with two bachelor’s and a master’s degree under her belt. She has been involved in sports for many decades and competed for Australia in the Commonwealth Games and Olympic Games marathons with a personal best time of 2 hours 28 minutes. For more information visit https://athletesanctuary.com.au/kate-smyth

References

Ganz, T. (2016). Hepcidin. Rinsho Ketsueki, 57(10), 1913-1917. DOI: 10.11406/rinketsu.57.1913.

Sim, M., Dawson, B., Landers, G., Trinder, D., & Peeling, P. (2014). Iron regulation in athletes: exploring the menstrual cycle and effects of different exercise modalities on hepcidin production. International journal of sport nutrition and exercise metabolism, 24(2), 177-187.https://pubmed.ncbi.nlm.nih.gov/24225901/

Alfaro-Magallanes, V. M., Benito, P. J., Rael, B., Barba-Moreno, L., Romero-Parra, N., Cupeiro, R. FEMME Study Group. (2020). Menopause Delays the Typical Recovery of Pre-Exercise Hepcidin Levels after High-Intensity Interval Running Exercise in Endurance-Trained Women. Nutrients, 12(12), 3866. https://pubmed.ncbi.nlm.nih.gov/33348847/

Nirengi, S., Taniguchi, H., Ishibashi, A., Fujibayashi, M., Akiyama, N., Kotani, K., & Sakane, N. (2021). Comparisons between serum levels of hepcidin and leptin in male college-level endurance runners and sprinters. Frontiers in Nutrition, 8. https://pubmed.ncbi.nlm.nih.gov/34136516/

Pagani, A., Nai, A., Silvestri, L., & Camaschella, C. (2019). Hepcidin and anemia: a tight relationship. Frontiers in physiology, 1294. https://www.frontiersin.org/articles/10.3389/fphys.2019.01294/full

Sim, M., Dawson, B., Landers, G., Trinder, D., & Peeling, P. (2014). Iron regulation in athletes: exploring the menstrual cycle and effects of different exercise modalities on hepcidin production. International journal of sports nutrition and exercise metabolism, 24(2), 177-187. https://pubmed.ncbi.nlm.nih.gov/24225901/[/vc_column_text][/vc_column][/vc_row]

10 signs of iron deficiency

athletesanctuary — Tue, 18 Jan 2022 14:00:00 +0000

Anaemia caused by iron deficiency is a condition in which there is not enough iron to form enough healthy red blood cells of sufficient size to carry oxygen to the tissues of the body.

Iron plays a crucial physiological role in your body. But despite its importance, iron deficiency anaemia is still a common problem among female athletes. Iron deficiency can have major adverse effects on your well-being and your athletic capacity.

It’s not uncommon for iron deficiency anaemia to be quite mild and go unnoticed. But women – and especially active, athletic women – are very prone to this condition. If gone untreated, the anaemia will worsen, and the signs and symptoms will intensify.

Without enough iron, your body can’t produce enough hemoglobin – the substance in red blood cells that enables them to carry oxygen – and as a result iron deficiency anaemia can leave you short of breath, headachy, tired, and unable to complete a training session or event with your usual enthusiasm. Iron deficiency is missed in 47-82% of females and 95-100% of male adolescents and young adult patients.

10 signs of iron deficiency

*Fatigue that starts even after a good night’s sleep

*Restless legs

*Nausea

*Bruising

*Pale or itchy skin

*Hair loss

*Shortness of breath

*Poor concentration and decision-making, “foggy brain”

*Rapid heartbeat or “fluttering feeling”

*Headache, dizziness or light-headedness

Keep in mind this is just a small number of the 75 known symptoms of iron deficiency. Unusual cravings for non-nutritive substances, such as ice and dirt

CAUSES OF IRON DEFICIENCY

Low or little dietary intake of iron-rich foods is often blamed as the key factor contributing to iron deficiency. With plant-based eating increasing in popularity amongst the athlete community, this is a key factor for many athletes. Lack of awareness of how to consume foods that enhance iron absorption or knowledge on sources of plant-based iron-rich foods can render an athlete with symptoms in a matter of months. Poor intake however is not the only cause of iron deficiency anaemia.

*Blood loss. Blood contains iron within red blood cells. If you lose blood, you lose some iron. Women with heavy periods are at risk of iron deficiency anaemia because they lose blood during menstruation. Athletes who are frequent blood donors are at increased risk for iron deficiency.¹ Athletes who regularly use nonsteroidal anti-inflammatories are likely to have increased gastrointestinal blood losses increasing their risk of iron deficiency³.

*An inability to absorb iron. Dietary iron is absorbed into the bloodstream through the small intestine. An intestinal disorder, such as celiac disease, stomach ulcers, ulcerative colitis or Crohn’s disease, which affects the intestine's ability to absorb nutrients from digested food, can lead to iron-deficiency anaemia. If part of the small intestine has been bypassed or removed surgically, the ability to absorb iron and other nutrients will be reduced. Inflammation in the digestive tract is aligned with symptoms such as bloating, gas, diarrhoea or constipation, food intolerances, or loud gurgling, and may signal the integrity of the gut lining may be compromised. Without good integrity, absorption of nutrients is also reduced.

*Low stomach acid. Adequate stomach acid (hydrochloric acid- HCL) is required to break down minerals such as iron and extract them from the food we eat. Low stomach acid is a common issue following times of prolonged physical or emotional stress and can be found alongside iron deficiency.

*Iron stealers. Bacteria overgrowth, Helicobacter pylori, and parasites within the digestive tract can impact the way iron is absorbed and may contribute to blood loss, therefore, contributing to iron deficiency over time.

*Post natal- Without iron supplementation, iron deficiency anaemia occurs in many pregnant women due to the iron requirements of the mother and baby. Post-natal iron deficiency can occur as many women are naturally preoccupied with their new arrival and forget to have adequate medical checkups for themselves. Fatigue is often experienced by mother’s and therefore iron deficiency can go undetected for many months. This depletes not only the mother but also the baby’s supply of iron who depends on the mother for iron for the first 6 months of life until solids are introduced.

Hundreds of athletes have used our handy anaemia quiz to help determine the likely risk of having low iron or anaemia. Find out if you are getting low on iron here.

Want to know more? Contact the Athlete Sanctuary to learn how we can support you further.

References

Choe, Y. H., Kwon, Y. S., Jung, M. K., Kang, S. K., Hwang, T. S., & Hong, Y. C. (2001). Helicobacter pylori-associated iron-deficiency anemia in adolescent female athletes. The journal of Pediatrics, 139(1), 100-104.
Eiduson, R., Heeney, M. M., Kao, P.-C., London, W. B., Fleming, M. D., & Shrier, L. A. (2022). Prevalence and Predictors of Iron Deficiency in Adolescent and Young Adult Outpatients: Implications for Screening. Clinical Pediatrics, 61(1), 66–75. https://doi.org/10.1177/00099228211059647
Safarova, K. N., Dorogoykina, K. D., & Rebrov, A. P. (2019). Is anemia a clinical marker of NSAID-induced upper gastrointestinal lesions in patients with spondyloarthritis?. Almanac of Clinical Medicine, 47(5), 410-418. https://doi.org/10.18786/2072-0505-2019-47-037
Hinton P. S. (2014). Iron and the endurance athlete. Applied physiology, nutrition, and metabolism = Physiologie appliquee, nutrition et metabolism, 39(9), 1012–1018. https://doi.org/10.1139/apnm-2014-0147
Mayo Clinic (2022). Iron Deficiency anemia. https://www.mayoclinic.org
Sim, M., Dawson, B., Landers, G., Trinder, D., & Peeling, P. (2014). Iron regulation in athletes: exploring the menstrual cycle and effects of different exercise modalities on hepcidin production. International journal of sports nutrition and exercise metabolism, 24(2), 177–187. https://doi.org/10.1123/ijsnem.2013-0067

Iron and thyroid function

athletesanctuary — Mon, 30 Nov 2020 14:00:00 +0000

Iron deficiency is one of the most common issues athletes face. Iron and thyroid health go hand in hand and the effects of exercise on the thyroid gland and hormones are not well understood.

Iron and thyroid function
Undiagnosed iron deficiency presents an increased risk of impaired thyroid function. Active women have high-energy lives, managing work, family and training, and many will accept low energy and brain fog as simply a result of being overworked or as an inevitable part of hormonal changes.

However, low thyroid function, iron deficiency, overtraining and hormonal changes also present with many of the same symptoms.

Signs that your thyroid function may be underactive (hypothyroid) include fatigue, unexplained weight gain, headaches, low blood pressure, dry skin, constipation and cold intolerance. These early signs of cellular hypothyroidism can appear when blood pathology remains within standard ranges.

As with most chronic issues, there are multiple factors that may contribute to dysfunction.

The Link between Exercise and Thyroid Function

In athletes, endurance and high-volume training promotes thyroid function. During exercise, your hypothalamus stimulates the pituitary gland to secrete thyroid-stimulating hormone (TSH), which in turn signals your thyroid to synthesise and release the thyroid storage hormone T4 and active thyroid hormone T3.

These hormones influence your body’s metabolism and allow it to increase exercise intensity. Over time, this repeated, high demand of your thyroid during prolonged intense exercise may impact your thyroid function, causing it to slow down and consequently lose the ability to produce sufficient hormones.

Iron and Thyroid Function

Normal thyroid function is dependent on several nutrients to regulate the synthesis of thyroid hormones. Iodine, iron, tyrosine, selenium, and zinc are needed to facilitate the conversion of T4 to T3 . A deficiency of any one of these nutrients would result in reduced T3 production, causing you to experience hypothyroid symptoms. Vitamins A and D also play important roles in cell receptor behaviour to regulate thyroid hormone metabolism.

While iodine is the key mineral for healthy thyroid function (read more…here) it is not uncommon to find iron deficiency in hypothyroidism. Although widely recognised for its influence on red blood cell production, iron is also an important component of thyroid peroxidase, an enzyme essential for thyroid hormone biosynthesis.

Iron deficiency interferes with the normal functioning of the thyroid, contributing significantly to fatigue, exercise intolerance and lightheadedness.

Increased menstrual bleeding can lead to iron deficiency. Many of us dismiss low energy as a symptom of a busy, active lifestyle and so iron deficiency frequently goes undiagnosed in perimenopausal women. For athletes, iron plays a critical role in exercise performance as outlined in our blog “Increase your iron absorption and rebound from anaemia” here

The most common causes of iron deficiency include inadequate dietary iron intake, inflammation, poor iron absorption in the gut, parasites, iron loss through sweat, urination and faeces, blood loss through menstruation. Pregnancy, breastfeeding or high-volume exercise will also significantly increase iron demands. Take our free anaemia quiz to see if you may be iron deficient here

Thyroid Function and Sex Hormones in Women

Your thyroid function is sensitive to fluctuations in sex hormone levels, particularly oestrogen. Oestrogen stimulates the production of the thyroid hormone precursor, thyroglobulin, and increases the protein that carries thyroid hormones in your blood.

As oestrogen changes (such as during peri-menopause) so too does thyroid hormones, which play an important role in metabolism, muscle strength, energy production and expenditure, heart function, and temperature regulation.

As oestrogen levels rise and fall later in life, menstruation may become irregular and heavier. Peri-menopausal women may experience symptoms for over ten years as described in our blog on “Natural solutions for menopause” here .

During peri-menopause declining oestrogen may impact thyroid function and can lead to inadequate production and circulation of thyroid hormones.

Exercise During Hormonal Changes

Despite common misconceptions, women can train and perform well throughout peri-menopause, and beyond, if they listen to their bodies and be mindful of maintaining adequate dietary intake of key nutrients. It is important to recognise that both iron deficiency, thyroid function and hormonal changes can impact your ability to exercise.

Years of consistent exercise accumulate like pages in a book. As a mature you know your body very well. The pathway to success utilises your book of wisdom and skills. Mature athletes can benefit from greater recovery, individualized strength and conditioning and modified programs. Focussing on the balance between training intensity and volume will help you to achieve your desired goals.

If you suspect your symptoms are impacting on your quality of life and sport, it’s time to seek support to help you navigate the journey.

Blood serum pathology and functional tissue mineral testing can be a good starting point due to the critical role nutrients play in hormonal and thyroid function.

With the right self-care and a holistic approach to health, you can continue to achieve your life goals and physical challenges irrespective of hormonal changes.

About the Author: Kate Smyth is a Sports naturopath, nutritionist and female-centric running coach. She is the founder of the Athlete Sanctuary- a holistic healthcare clinic for athletes of all levels and sporting codes. Kate has a thirst for knowledge with two bachelor’s and a master’s degree under her belt. She has been involved in sports for many decades and competed for Australia in the Commonwealth Games and Olympic Games marathons with a personal best time of 2 hours 28 minutes. For more information visit https://athletesanctuary.com.au/kate-smyth

References

Kawicka, A., & Regulska-Ilow, B. (2015). Metabolic disorders and nutritional status in autoimmune thyroid diseases. Postepy Higieny i Medycyny Doswiadczalnej, 69, 80–90.
Luksch, J. R., & Collins, P. B. (2018). Thyroid Disorders in Athletes. Current Sports Medicine Reports, 17(2), 59–64.
Santin, A. P., & Furlanetto, T. W. (2011). Role of estrogen in thyroid function and growth regulation. Journal of Thyroid Research, 2011.
Soliman, A. T., De Sanctis, V., Yassin, M., Wagdy, M., & Soliman, N. (2017). Chronic anemia and thyroid function. Acta Biomedica, 88(1), 119–127.
Wouthuyzen-Bakker, M., & Van Assen, S. (2015). Exercise-induced anaemia: A forgotten cause of iron deficiency anaemia in young adults. British Journal of General Practice, 65(634), 268–269.