Question for Fast Talk Ep 205 with Dr. San Millan on Recovery: Hemoglobin and Iron Confusion

I found this episode especially interesting, esp around potentially mis-diagnosing Hypothyroidism. I have passed the episode on to 2 sports medicine GPs.

Later in the episode, there was a discussion of the low hemoglobin, starting around 46:50 in the transcript. And it seemed to me that Dr Dr. San Millan was pointing out that low hemoglobin in athletes may be muscle damage and some stage of over-training, while in the next section, it seemed to me that Jeff Winkler was saying that low performance being tied to low iron and that iron injections solved the problem.

I certainly may be confused - and maybe the situation Dr San Millan is discussing is not the same situation that Jeff Winkler is discussing, but I would appreciate any clarifying information on this section of the podcast.

thanks so much for all of the super useful information you have provided over many years.

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As I remember, it was a matter of good ferritin levels in the case mentioned by Dr. San Milan. That’s why he supposed that iron deficiency is not a problem - the problem lies in the body not being able to use that iron. So we can assume that with Jeff Winkler’s case, in contrary, the matter was low ferritin.

Thus, when one is concerned about who should he listen ( :smiley: ) the best option is to do a blood analysis and check the ferritin levels. If they’re fine - try Dr. San Milan’s explanation and lower the training load with no changes in diet. If ferritin levels are low - try Jeff Winkler’s explanation and look for ways to increase the iron level.

I had a similar concern listening to the discussion about hypothyroidism. I think that Dr. San Millan is correct to point out that when overtrained athletes go to their doctor they will get a work up that might turn up erroneous diagnoses such as hypothyroidism or anemia. On that point, it is good for him to emphasize that doctors need to understand that overtraining can mimic a variety of endocrine or hematologic disorders and to not rush to label overtraining as something like hypothyroidism.

I happen to be a hematologist and found this section of the conversation to be potential confusing to listeners. Jeff Winkler is describing the fact that highly trained athletes, often runners, may develop mild iron deficient anemia. This will be easily diagnosed with simple blood tests showing a very low serum ferritin. Personally, I would want to see that he really failed oral iron supplementation before giving IV iron but I can believe that iron deficiency would make him feel poorly both from anemia and from the deficiency itself. What Dr. SM is describing is something slightly different. He is saying you can have athletes who have adequate substrate for erythroposesis (ie B12, folate and iron) but fail to produce sufficient red cells. I haven’t gone back to literature to see how prevalent this is but if we take it at face value, getting IV iron or extra vitamins isnt going to help. There is a well known condition called anemia of chronic inflammation which we see with patients with autoimmune disorders such as lupus or rheumatoid arthritis where the ferritin is actually elevated as it is also an inflammatory marker. I haven’t dug into the literature to see if there are papers showing that athletes can create a similar situation from overtraining or not. But if I were to see something like this in an athlete, I would advise backing off on training (which is what I think Dr. SM is getting at) and not trying something like IV iron or extra vitamins. Oh an one final wrinkle is that there is something called pseudo-anemia wiht athletes were due to increased plasma volume you get a dilution of the hematocrit/hemoglobin. This isnt a real anemia as the total red cell mass in the body isnt changed but just simply diluted.


thanks so much to both of you for your replies! That info will help as I talk with my GP about annual physical and bloodwork next week.

The podcast and how we understand it makes it clear to me that the serious (recreational) athlete should always keep a close eye on key metric trends such as rest HR, HRV, temperature and feel. If these are neglected we might go down the path of deteriorating the basics ending up with a medical issue.
The average family doctor (my impression) is not used to treating athletes, which might cause the initial diagnoses to be wrong.
I recall a case where i asked for testing as my rest HR was over 60…the doctor did not really understand the implications of my statement until i explained the structural HR tracking and normal resting values.

I would be great to do a preventing blood sample test every quarter. Do professional athletes do that?