What is the best treatment for iron deficiency in a high-level amateur triathlete with fatigue and decreased performance?

Treatment of Iron Deficiency in a High-Level Amateur Triathlete

Oral iron supplementation with ferrous sulfate 65 mg (equivalent to 324 mg ferrous sulfate) taken once daily or on alternate days is the recommended treatment for your iron deficiency, which is likely contributing to your fatigue and decreased performance. 1

Diagnosis Assessment

Based on your lab values:

• Hemoglobin: 15.7 (normal)
• Ferritin: 34 ng/mL (low for athletes)
• Iron binding capacity: 361 (high normal)
• Saturation: 29% (normal)
• Total iron: 104 (normal)

You have non-anemic iron deficiency, which is common in endurance athletes. While your ferritin level of 34 ng/mL would be considered borderline normal in the general population, for athletes:

• Ferritin <35 μg/L indicates iron deficiency 1
• Athletes should maintain higher ferritin levels (>30-50 μg/L) for optimal performance 1, 2

Treatment Protocol

First-line Treatment:

1. Oral Iron Supplementation:

   • Ferrous sulfate 65 mg of elemental iron (324 mg tablet) daily or on alternate days 1, 3, 4
   • Take on an empty stomach for best absorption
   • Take with vitamin C (orange juice or supplement) to enhance absorption 1
   • Avoid taking with tea, coffee, calcium, or dairy products which inhibit absorption

2. Dietary Modifications:

   • Increase consumption of iron-rich foods, particularly red meat (heme iron) 1
   • Include vitamin C-rich foods with meals to enhance non-heme iron absorption
   • Avoid tea and coffee around meals as they inhibit iron absorption

Monitoring:

• Repeat iron studies after 8-10 weeks of supplementation 1
• Target ferritin level should be >50 μg/L, especially for endurance athletes 2
• For athletes planning altitude training, aim for ferritin values of 50 μg/L or higher 2

Second-line Treatment (if oral supplementation fails):

• Consider intravenous iron if:
  • Oral iron is not tolerated (GI side effects)
  • Ferritin levels don't improve after 8-10 weeks
  • Rapid correction is needed for upcoming competition 1

Special Considerations for Athletes

1. Performance Impact:

   • Iron deficiency without anemia can significantly impair endurance performance 1, 2
   • Even non-anemic iron deficiency affects aerobic capacity and recovery 1
   • Symptoms like fatigue and decreased performance may improve with correction of iron status

2. Causes of Iron Deficiency in Athletes:

   • Increased iron demands due to training (expanded blood volume)
   • Exercise-induced hemolysis (foot strike, mechanical trauma)
   • Gastrointestinal blood loss during intense exercise
   • Hepcidin increases after intense exercise, blocking iron absorption 2
   • Potentially inadequate dietary intake 5

3. Pitfalls to Avoid:

   • Don't supplement iron without confirmed deficiency (risk of iron overload) 6
   • Don't continue long-term supplementation without monitoring ferritin levels 2
   • Don't ignore persistent symptoms if iron levels improve (may indicate other issues)
   • Don't expect immediate performance improvements (allow 2-3 months for full effect)

Training Modifications During Treatment

• Consider temporarily reducing high-intensity training volume until iron stores improve
• Focus on quality over quantity in workouts
• Ensure adequate recovery between training sessions
• Monitor subjective fatigue levels and adjust training accordingly

By addressing your iron deficiency with appropriate supplementation and dietary changes, you should see improvements in energy levels, training capacity, and performance within 2-3 months as your iron stores are replenished.