What Stephanie Bruce, one of America’s fastest runners, looks for in a blood test

Most professional distance runners in the United States are prodigies who win titles at races like Foot Locker High School Cross Country Championships and NCAA Track and Field Championships then immediately jump into the pro races with aplomb. However a small number take a different path. They slowly rise to the top, steadily navigating a winding road and learning to extract every second of speed from their bodies. One of those is Stephanie Bruce, who has gone from a relatively unheralded early career to a 35 year old mom of two boys who can lay claim, at this halfway point in the year, to being the most accomplished American distance runner of 2019. Thus far she is the US’s best cross country runner via her 33rd at the World Cross Country Championship; the US’s best half marathoner via her win at that distance’s USATF National Championship; and the 4th fastest outdoor 5k runner with her 15:17 PB at the USATF Distance Classic on May 16th.

To compete at this level and race her best, Stephanie regularly tests with Athlete Blood Test. I talked with Stephanie to learn more about how this helps her.

Q: In college your iron related ferritin level was a 4 when a normal level is 15-150. Knowing your history, do you feel like more athletes should get their blood levels checked?

A: I do. Firstly, you want to have a baseline as a starting point. That way things that come up like illnesses or life stresses won’t confuse you and then you’ll have a normal point to work off of. It’s one piece of the puzzle that is essential as an athlete.

Q: Does knowing your blood levels give you confidence going into races?

A: Now it does. When I started to struggle around two years ago I had some bad performances and I didn’t know what was going on. Then I got introduced to the team at Athlete Blood Test and the profile of not just ferritin but so many nutrients and vitamins that I didn’t understand. Once I figured out the correlation between those and my energy levels then I started to feel better. Now I’m seeing performances that are truly indicative of me firing on all cylinders. Now I know what’s ideal for me and I feel like I have it really dialed in.

Q: Is there a blood level marker that is important to you and you know you feel good when it’s ideal?

A: Yeah, looking at hemoglobin and hematocrit are crucial. Hematocrit can be affected by hydration levels but 9 out of 10 times when I start to feel bad, I’m sluggish, or my energy is low then my hematocrit is a point lower than it should be. Now I know that one point of hematocrit is very significant when it comes to performance.

Q: Have you been able to solve the ferritin issues that challenged you in the past?

A: Yes, now my ferritin is rocking. Once I figured out that I had Celiac and that I had absorption issues then I went from 4 to the 40’s in the first couple years and now I can get it anywhere between 60 and 80 and that’s phenomenal for me.

Q: Is there a critical time of year to get your blood levels checked?

A: I try to do it very regularly,  every 8 to 10 weeks. I focus more on it when I start to do heavy marathon training because my levels can change rapidly when I’m running 110 to 160 mile weeks. There’s also something with the winter, possibly due to the lack of sunshine and vitamin D levels. It’s an especially important time to get levels checked.

Q: As an athlete, is there anything else you’ve learned through the years about monitoring your blood levels?

A: Context is important when looking at blood levels. With my B12 and folate, my team couldn’t figure out what was going on and it took me some time to determine that taking B12 can be bad for me and can give me the same effect as having anemia. I was taking vitamin B12 and I was feeling worse. I did a gene test and I figured out that I have a gene that affects B12 and supplementing B12 is bad for me. Food and nutrition are my first go-tos to increase blood levels but due to my Celiac that can be hard and I can’t follow standard recommendations. As a result, you have to delve deep into blood levels and it has to be very individually based.

We wish Stephanie continued success this season. She will compete at the United States Outdoor Championships in July in Des Moines, Iowa. There, she can qualify for the World Outdoor Championships in September/October in Doha, Qatar. You can learn more about Stephanie on: her website or the Hoka One One Northern Arizona Elite Team website.

Written on June 28, 2019
By Jordan J

Maximizing Your Potential: Hemoglobin and Oxygen Delivery

Marginal gains. The term “marginal gains” is being heard more and more in the world of sports. The concept of marginal gains is simple. What are the little (marginal) things you can improve that cumulatively result in overall performance improvements? As a performance adviser to many of the
world’s top endurance athletes, it is my job to identify where marginal gains can be made physiologically. One focus is oxygen availability, and a key player is hemoglobin, a protein in red blood cells. Hemoglobin is a micro-sized protein that has macro-sized effects on performance. And what you eat on a daily basis can affect hemoglobin levels.

Put simply, endurance exercise is largely characterized by a simple requirement; sustaining repeated muscle contraction. This criterion is
fulfilled via two basic functions, the ability to consume enough oxygen and adequate fueling. Regarding fueling, that is another topic, however summarized by simply providing the right fuels at the right time during activity. Regarding oxygen, the process is a bit more complex.
Muscles require oxygen to convert sugars into energy. In the absence of replenishing oxygen, muscles reach complete exhaustion in just a few
minutes. Therefore, endurance athletes require constant oxygen delivery to the muscles. It is hemoglobin that carries oxygen to the muscles.
Hemoglobin picks up oxygen in the lungs and delivers it to the tissues of the body, most notably your muscles. Hemoglobin levels have a direct
impact on endurance exercise performance. Lower levels of hemoglobin causes decreased efficiency of oxygen delivery to the muscles. The result is more rapid muscle fatigue, decreased VO2max, and higher heart rates. As a dramatic example, if you have ever exercised at high altitude, you know what it feels like to have less oxygen delivered to the muscles.

Certain micronutrients are essential in the formation of hemoglobin. Because of the high turnover rate of red blood cells and hemoglobin in endurance athletes, the dietary requirements of these micronutrients are higher than the average person. Failing to replenish them can result in a decrease in hemoglobin production, and thus performance.
Iron, folate, and vitamin B12 are directly involved in hemoglobin formation. Other micronutrients, such as vitamin B9, vitamin C, copper,
and vitamin A are indirectly involved in hemoglobin formation. Although the goal in replenishing micronutrients should be through dietary means, many athletes require supplementation at some point in the season.
To put this in an easily understood context, let me share a real-life case study.
A pro triathlete presents for routine monitoring. She has transitioned over the last nine months from the ITU circuit to the Ironman 70.3 and Ironman distances. She has been tolerating the training well and does not have complaints. Being new to the higher volume she does not know what to expect.

Blood work revealed low-normal hemoglobin (12.0), hematocrit (36.2), small platelets (MPV 6.5), and borderline large red blood cells (MCV 99.7). These findings are consistent with her prior test results during training. Micronutrients were tested as well and revealed a mild functional folate deficiency (within the low limits of the “normal range”, but given the high turnover rate of folate in a female endurance athlete her levels indicate a deficiency in these circumstances).

Intervention included significantly increasing dietary intake of folate and two weeks of supplementation. Follow up tests were performed each week for the following four weeks.

Follow-up #1: Folate
16.2, Hemoglobin 12.4, Hematocrit 37.7
Follow-up #2: Folate
18.8, Hemoglobin 12.7, Hematocrit 38.2
Follow-up #3: Folate
>20.0, Hemoglobin 13.1, Hematocrit 40.4
Follow-up #4: Folate
>20.0, Hemoglobin 14.2, Hematocrit 44.8 (following 5 days of taper)

There is little doubt that the 15% increase in hemoglobin achieved in the case study above will result in improved performance, and this
particular athlete’s performance last year confirms. In this example we must consider the effects of coming from sea level to 5,600 feet of elevation. However, these changes significantly exceed what would be expected for acclimation at this elevation, and the red blood cell indices were highly suggestive of a folate repletion effect being the primary driver behind the improvements. Thus, much of this change was the result of simply making an adequate amount of micronutrients available to keep up with the high turnover of red blood cells, and thus hemoglobin.
As an endurance athlete, your dietary requirements of
certain micronutrients are increased. Regarding oxygen delivery to the muscles,
iron, folate, vitamins B9 and B12, vitamin C, copper, and vitamin A are
critical to optimizing hemoglobin levels. Be sure you are eating ample amounts
of foods high in these micronutrients. Doing so will aid in optimal oxygen
delivery to the muscles, and thus help you perform at your highest potential.
The following table shows foods high in each of these
essential micronutrients.

(Vitamin B9)
Red Meat
Beans and Lentils
Egg Yolks
Dark, Leafy Greens
Red Meat
Dark, Leafy Greens
Asparagus and Broccoli
Dried Fruit
Romaine Lettuce
Beans and Lentils
Yogurt and Milk
Oranges and Tropical Fruits
Fortified Vegan Products
Sunflower and Sesame Seeds
Peppers (Chili and Bell)
Dark, Leafy Greens
Cocoa Powder
Broccoli and Cauliflower
Sundried Tomatoes
Sunflower and Sesame Seeds
Calamari and Lobster
Thyme and Parsley
Dried Herbs
Pine Teas
Written on February 11, 2016
By Jordan J

Why Eating Disorders In Endurance Athletes Are Especially Dangerous

It is time for those of us involved in endurance sports to bring attention to the problem of eating disorders in endurance athletes. I hope you will help address this problem by sharing this post with every runner, triathlete, and cyclist you know. Thank you.

The topic of eating disorders in endurance athletes is too often neglected. The numbers are staggering. Studies show that up to 25% of female and 10% of male endurance athletes have either a subclinical or clinical eating disorder. In a population dominated by highly motivated, highly disciplined, perfectionist personalities, we are all at risk of developing an eating disorder. Yet, it continues on without much attention, and in fact often unintentionally persuaded through publications talking about lighter being faster, ideal race weight, and on and on.

Even more staggering than the frequency are the long term implications of eating disorders in endurance athletes, especially when they occur during adolescence.

Eating disorders in endurance athletes tend to be different. Although plenty fall in line with the classic definitions of specific eating disorders, many do not. For example, excessive exercise is simply part of training, not a “sign” of an eating disorder. Endurance athletes must eat to train, and rarely is prolonged anorexia a problem. Athletes eat. Most often, an “eating disorder” in an endurance athlete is simply inadequate fueling during training. But, where is that line?

Eating disorders cause problems in endurance athletes. Stress fractures, hormone disorders, poor bone development, malabsorption, and micronutrient deficiencies are just some of them. They also can cause significant health problems later in life, such as osteoporosis and hip fractures, which substantially increase the risk of death and major morbidity. The biggest problem with eating disorders is that many of the consequences don’t present until long after the eating disorder is corrected. The treatment is prevention.

Some of the Long Term Consequences of Eating Disorders In Endurance Athletes

Bone Mass

The most critical period of bone mass development is adolescent years to late teens/early twenties. During this time, your body is rapidly increasing bone mass to keep up with growth. If bone mass development is compromised, such as in cases of malnutrition due to eating disorders, peak bone mass will be reduced. The consequences are significantly increased risk for stress fractures throughout the span of the athletic years, and risk for osteoporosis later in life. Osteoporosis greatly increases the risk of fractures, physical deformity, organ compression, chronic pain, and overall morbidity and mortality. Hip fractures, one of the most well-known consequences of osteoporosis, have a 15-37% 1 year mortality rate in people over age 65.

Hormone Disorders
Studies show that inadequate fueling amidst excessive exercise can reduce thyroid function. This may occur by way of impacting adrenal function, and thus cortisol levels, or it may be secondary to reduced dietary fat and/or reduced body fat. Science has posed and supported all of these pathways, however they all lead to one causative factor, inadequate fueling (eating disorder) during training. Hormones are critical to our well-being, and performance. The types of hormone disorders sparked by inadequate fueling during training can cause excessive fatigue, decreased muscle recovery (by way of the HPA axis and growth hormone), mood swings, sleep problems, compromised immunity, and more. 
Malnutrition has far reaching consequences. For the sake of keeping this article short, let’s just address one thing that matters much to athletes, performance. Nutrients are what keep our cells going. A deficiency in intake often leads to a deficiency in function. For example, for red blood cells to replicate, iron, B12, folate, and several other micronutrients are essential. Red blood cells are destroyed at high rates in training endurance athletes. In response, your body will produce new cells. If the necessary micronutrients are not readily available, the process of new red blood cell production will be limited, which can result in fatigue, decreased performance, and anemia. The citric acid cycle (or Kreb’s cycle) is driven by micronutrients. These are just two examples of many. There are countless pathways critical to performance that rely 100% on the availability of micronutrients. And for that matter…life relies 100% on it as well. 
Absorption Problems and Food Sensitivities?
I typically prefer to stick to writing scientific supported information. However, in my experience working with professional, elite, and recreational endurance athletes, I have noted an interesting correlation between past eating disorders and current micronutrient absorption problems and often food sensitivities. I have yet to find any research on this (if you have please share it!), yet the correlation is so strong that I feel confident in sharing it.
Eating disorders ruin careers. They have far-reaching effects that follow people long after recovery, especially athletes.The predisposition for eating disorders in endurance athletes is strong. There are many reasons endurance athletes might develop eating disorders, ranging from body image to performance. While the tendency is to attempt to address the “underlying problem” (via counseling), doing so is complicated, as it varies per individual. However, I believe that by making the long term consequences of eating disorders in endurance athletes known, we can reduce the incidence. It is working with smoking. We have reduced smoking from 42% of adults in 1965 to 19% of adults in 2011. Eating disorders in endurance athletes can have implications nearly as serious as smoking. 

An eating disorder in an endurance athlete is often unidentifiable. Athletes eat. By definition, an eating disorder in an athlete simply means inadequate fueling during training. There are very few circumstances when an athlete increasing training should be concurrently dieting. If this is a desired combination, it should be done under careful monitoring by a health care professional familiar with the dangers of dieting while training. 

Written on
By Jordan J