Skip to main content

Iron Status in Athletes

An Update

Summary

As more studies are done on the iron status of athletes, the significance of apparent iron deficiency remains controversial. Do observed changes in iron status in athletes indicate an actual iron deficiency or a physiological response to exercise? Iron replacement would clearly be indicated if an iron deficiency was present but would not be necessary or effective if the observed changes were simply a physiological response. There is agreement that serum ferritin and haemoglobin decrease with some exercise conditions and that some indicators of haemolysis, such as serum haptoglobin and bilirubin, change in response to exercise. Expansion of plasma volume and the shift of iron storage from bone marrow to the liver could support the claim that the apparent reduced iron status parameters occurring with exercise are misleading. Countering this concept are studies in athletes which demonstrate dietary iron intake deficiencies and blood loss in the gastrointestinal and urinary tract. Iron deficiency is common in the general population, particularly in women. Therefore, continued monitoring of iron status in athletes appears justified in the face of present knowledge. Replacement therapy, when iron deficiency is apparent, is recommended.

This is a preview of subscription content, access via your institution.

References

  1. Andersen HT, Barkve H. Iron deficiency and muscular work performance. Scandinavian Journal of Clinical and Laboratory Investigation 25 (Suppl. 114): 1–62, 1970

    Google Scholar 

  2. Aronson V. Ancient Man’s meat. Runners World, August 21, 1985

  3. Banister EW, Hamilton CL. Variations in iron status with fatigue modelled from training in female distance runners. European Journal of Applied Physiology 54: 16–23, 1985

    CAS  Google Scholar 

  4. Bannerman RM, Beveridge BR, Witts, LJ. Anaemia associated with unexplained occult blood loss. British Medical Journal 1: 1417–1419, 1964

    PubMed  CAS  Google Scholar 

  5. Blacklock N. Bladder trauma in the long distance runner: ‘10,000 meters haematuria’. British Journal of Urology 49: 129–132, 1977

    PubMed  CAS  Google Scholar 

  6. Blum SM, Sherman AR, Boileau RA. The effects of fitness-type exercise on iron status in adult women. American Journal of Clinical Nutrition 43: 456–463, 1986

    PubMed  CAS  Google Scholar 

  7. Boileau M, Fuchs E, Barry J, Hodges C. Stress hematuria: athletic pseudo-nephritis in marathoners. Urology 15 (5): 471–474, 1980

    PubMed  CAS  Google Scholar 

  8. Bothwell TH, Charlton RW, Cook JD, Finch CA. Iron metabolism in man, Blackwell Scientific Publications, Oxford, 1979

    Google Scholar 

  9. Brotherhood J, Brozovie, B, Pugh LGC. Haematological status of middle and long distance runners. Clinical Science and Molecular Medicine 48: 139–145, 1975

    PubMed  CAS  Google Scholar 

  10. Brune M, Magnusson B, Persson H, Hallberg L. Iron losses in sweat. American Journal of Clinical Nutrition 43: 438–443, 1986

    PubMed  CAS  Google Scholar 

  11. Buckman MJ. Gastrointestinal bleeding in long distance runners. Annals of Internal Medicine 101: 127–128, 1984

    PubMed  CAS  Google Scholar 

  12. Charlton RW, Derman D, Skikne B, Torrance JD, Lynch SR, et al. Anemia, iron deficiency and exercise: extended studies in human subjects. Clinical Science and Molecular Medicine 53: 537–541, 1977

    PubMed  CAS  Google Scholar 

  13. Clement DB, Asmundson RC. Nutritional intake and hematological parameters in endurance runners. Physician and Sports Medicine 10(3): 37–43, 1982

    Google Scholar 

  14. Clement DB, Asmundson RC, Medhurst CW. Hemoglobin values: comparative survey of the 1976 Canadian Olympic team. Canadian Medical Association Journal, 117: 614–616, 1977

    PubMed  CAS  Google Scholar 

  15. Clement DB, Sawchuk LL. Iron status and sports performance. Sports Medicine 1: 65–74, 1984

    Google Scholar 

  16. Colt E, Heyman B. Low ferritin levels in runners. Journal of Sports Medicine, 24: 13–17, 1984

    CAS  Google Scholar 

  17. Committee on Dietary Allowances, Food and Nutrition Board, National Research Council recommended dietary allowances, 9th review ed., National Academy of Sciences, Washington, 1980

    Google Scholar 

  18. Cook JD, Alvarado J, Gutnisky A, Jamra M, Labardini J, et al. Nutritional deficiency and anemia in Latin America: a collaborative study. Blood 38: 591–603, 1971

    PubMed  CAS  Google Scholar 

  19. Cooper BT, Douglas SA, Firth LA, Hannagan JA, Chadwick VS. Erosive gastritis and gastrointestinal bleeding in a female runner. Gastroenterology 92: 2019–2023, 1987

    PubMed  CAS  Google Scholar 

  20. Dallman PR. Manifestations of iron deficiency. Seminars in Hematology 19(1): 19–30, 1982

    PubMed  CAS  Google Scholar 

  21. Dallman PR, Beutler E, Finch BA. Effects of iron deficiency exclusive of anemia. British Journal of Haematology 40: 179–184, 1978

    PubMed  CAS  Google Scholar 

  22. Davidson RJL. Exertional haemoglobinuria: a report on three cases with studies on the haemolytic mechanism. Journal of Clinical Pathology 17: 536–540, 1964

    PubMed  CAS  Google Scholar 

  23. Davidson RJL. March or exertional haemoglobinuria. Seminars in Hematology 6: 150–161, 1969

    PubMed  CAS  Google Scholar 

  24. Davidson RJL, Robertson JD, Galea G, Maughan RJ. Hematological changes associated with marathon running. International Journal of Sports Medicine 8: 19–25, 1987

    PubMed  CAS  Google Scholar 

  25. Davies KJA, Maguire JJ, Brooks GA, Dallman PR, Packer L. Muscle mitochondrial bioenergetics, oxygen supply and work capacity during dietary iron deficiency and repletion. American Journal of Physiology 242: E418–E427, 1982

    PubMed  CAS  Google Scholar 

  26. De Wijn JF, DeJongste JL, Mosterd W, Willebrand D. Hemoglobin, packed cell volume, serum iron and iron binding capacity of selected athletes during training. Nutritional Metabolism 13: 129–139, 1971

    Google Scholar 

  27. Dickson DN, Wilkinson RL, Noakes TD. Effects of ultramarathon training and racing on hematologic parameters and serum ferritin levels in well trained athletes. International Journal of Sports Medicine 3: 111–117, 1982

    PubMed  CAS  Google Scholar 

  28. Diehl DM, Lohman TG, Smith SC, Kertzer RJ. The effects of physical training on iron status of female field hockey players. International Journal of Sports Medicine 7: 264–270, 1986

    PubMed  CAS  Google Scholar 

  29. Dufaux B, Hoedcrath A, Streitberger I, Hollman W, Assmann G. Serum ferritin, haptoglobin and iron in middle and long distance runners, elite rowers, and professional racing cyclists. International Journal of Sports Medicine 2: 43–46, 1981

    PubMed  CAS  Google Scholar 

  30. Edgerton VR, Bryant SL, Gillespie CA, Gardner GW. Iron deficiency anemia and physical performance and activity of rats. Journal of Nutrition 102: 382–400, 1972

    Google Scholar 

  31. Ehn L, Carmark B, Hoglund S. Iron status in athletes involved in intense physical activity. Medicine and Science in Sports and Exercise 12 (1): 61–64, 1980

    PubMed  CAS  Google Scholar 

  32. Eichner ER. Runners macrocytosis: a clue to footstrike hemolysis. American Journal of Medicine 78: 321–325, 1985

    PubMed  CAS  Google Scholar 

  33. Ekblom B, Goldburg A, Gullbring B. Response to exercise after blood loss and reinfusion. Journal of Applied Physiology 33: 175–180, 1972

    PubMed  CAS  Google Scholar 

  34. Ericsson P. The effect of iron supplementation on the physical work capacity in the elderly. Acta Medica Scandinavica 188: 361–374, 1970

    PubMed  CAS  Google Scholar 

  35. Fairbanks VF, Beutler E. Iron deficiency. In Williams et al. (Eds) Hematology, 3rd ed., McGraw-Hill Book Co., 1983

    Google Scholar 

  36. Falsetti HL, Burke ER, Feld RD, Frederick ED, Ratering D. Hematological variations after endurance running with hard- and soft-soled running shoes. Physician and Sportsmedicine 11 (8): 118–127, 1983

    Google Scholar 

  37. Finch CA, Miller LR, Inamdar AR, Person R, Seiler K, et al. Iron deficiency in the rat: physiological and biochemical studies of muscle dysfunction. Journal of Clinical Investigation 58: 447–453, 1976

    PubMed  CAS  Google Scholar 

  38. Finch CA, Gollnick PO, Hlastala MP, Miller LR, Dillman E, et al. Lactic acidosis as a result of iron deficiency. Journal of Clinical Investigation 64: 129–137, 1979

    PubMed  CAS  Google Scholar 

  39. Finch CA. Drugs effective in iron deficiency and other hypochromic anemias. In Gilman et al. (Eds) The pharmacological basis of therapeutics, 6th ed., Chapter 56, MacMillan, 1980

    Google Scholar 

  40. Fisher RL, McMahon Jr LF, Ryan MJ, Larson D, Brand M. Gastrointestinal bleeding in competitive runners. Digestive Diseases and Sciences 31 (11): 1226–1228, 1986

    PubMed  CAS  Google Scholar 

  41. Frederickson LA, Puhl JL, Runyan WS. Effects of training on indices of iron status of young female cross-country runners. Medicine and Science in Sports and Exercise 15 (4): 271–276, 1983

    PubMed  CAS  Google Scholar 

  42. Ganong WF. Review of medical physiology, 10th ed., pp. 378, 379, 246, 416, Lange Medical Publications, Los Altos, California, 1981

    Google Scholar 

  43. Gardner GW, Edgerton VR, Senewiratne B, Barnard RJ, Ohira Y. Physical work capacity and metabolic stress in subjects with iron deficiency anemia. American Journal of Clinical Nutrition 30: 910–917, 1977

    PubMed  CAS  Google Scholar 

  44. Guyton AC. Basic human physiology: normal function and mechanisms of disease, 2nd ed., pp. 59–60, W.B. Saunders Co., Philadelphia, 1977

    Google Scholar 

  45. Hallberg L. Iron. In Hagsted et al. (Ed) Nutrition reviews: present knowledge in nutrition, 5th ed., 53, Nutrition Foundation Inc., Washington DC, 1984

    Google Scholar 

  46. NuHallberg L, Magnusson B. The etiology of ‘sports anemia’. Acta Medica Scandinavica 216: 145–148, 1984

    Google Scholar 

  47. Hayashi M, Kume T, Nihira H. Abnormalities of renal venous svstem and unexplained renal haematuria. Journal of Urology 124(1): 12–16, 1980

    PubMed  CAS  Google Scholar 

  48. Haymes EM. Iron deficiency and the active woman. In Harrif (Ed.) DGWS research reports: women in sport. Vol. 11, pp. 91–97, Washington AAHPER Press, 1973

    Google Scholar 

  49. Haymes EM, Puhl JL, Temples TE. Training for cross country skiing and iron status. Medicine and Science in Sports and Exercise 18(2): 162–167, 1986

    PubMed  CAS  Google Scholar 

  50. Health and Welfare Canada. Nutrition Canada: the British Columbia survey report, pp. 107–115, Supply and Services, 1975

    Google Scholar 

  51. Health and Welfare Canada. Recommended nutrient intakes for Canadians, pp. 120–136, Supply and Services, 1983

    Google Scholar 

  52. Heinrich HC. Intestinal iron absorption in man: methods of measuring dose relationship, diagnostic and therapeutic applications. In Hallberg et al. (Eds) Iron deficiency: pathogenesis, clinical aspects, therapy, pp. 213–296, Academic Press, New York, 1970

    Google Scholar 

  53. Heinrich HC, Bruggemann J, Gabbe EE, Glaser M. Correlation between diagnostic 59FE2+ absorption and serum ferritin concentration in man. Zeitschrift für Naturforschung 32 (e): 1023–1025, 1977

    CAS  Google Scholar 

  54. Hunding A, Jordal R, Pauler PE. Runners anemia and iron deficiency. Acta Medica Scandinavica 209: 315–318, 1981

    PubMed  CAS  Google Scholar 

  55. Jacobs A. Ferritin: an interim review. Current Topics in Hematology 5: 25–62, 1985

    PubMed  CAS  Google Scholar 

  56. Jacobs A, Milien LE, Worwood M, Beamish MR, Wardrop CA. Ferritin in the serum of normal subjects and patients with iron deficiency and iron overload. British Medical Journal 4: 206–208, 1972

    PubMed  CAS  Google Scholar 

  57. Kirschman JD. Nutrition almanac, 2nd ed., pp. 75–76, 120–121, 152, Nutrition Search Inc., McGraw-Hill Book Co., New York, 1984

    Google Scholar 

  58. Klausner RD, Harford JB, Rao K, Mattia E, Weissman AW, et al. Molecular aspects of the regulation of cellular iron metabolism. In Spik et al. (Eds) Proteins of iron storage and transport, pp. 111–122, Elsevier Science Publishers, Amsterdam, 1985

    Google Scholar 

  59. Lampe JW, Slavin JL, Apple FS. Poor iron status of women runners training for a marathon. International Journal of Sports Medicine 7(2): 111–114, 1986

    PubMed  CAS  Google Scholar 

  60. Letsky EA, Milleer F, Worwood M, Flynn DM. Serum ferritin in children with thalassaemia regularly transfused. Journal of Clinical Pathology 27: 652–655, 1974

    PubMed  CAS  Google Scholar 

  61. Lindemann R, Ekanger R, Opstad PK, Nummestad M, Ljostand R. Haematological changes in normal men during prolonged severe exercise. American Corrective Therapy Journal 32 (4): 107–111, 1978

    PubMed  CAS  Google Scholar 

  62. Mackler B, Grace R, Finch CA. Iron deficiency in the rat: effects on oxidative metabolism in distinct types of skeletal muscle. Pediatric Research 18 (6): 499–500, 1984

    PubMed  CAS  Google Scholar 

  63. Magnusson B, Hallburg L, Rossander L, Swolin B. Iron metabolism and ‘sports anemia’. Acta Medica Scandinavica 216: 149–164, 1984

    PubMed  CAS  Google Scholar 

  64. Matter M, Stitotfall T, Graves J, Myburgh K, Adams B, et al. The effect of iron and folate therapy on maximal exercise performance in female marathon runners with iron and folate deficiency. Clinical Science 72 (4): 415–422, 1987

    PubMed  CAS  Google Scholar 

  65. McCabe ME, Peura DA, Kadakia SC, Bocek Z, Johnson LF. Gastrointestinal blood loss associated with running a marathon. Digestive Diseases and Sciences 31 (11): 1229–1232, 1986

    Google Scholar 

  66. McLane JA, Fell RD, McKay RH, Winder WW, Brown EB, et al. Physiological and biochemical effects of iron deficiency on rat skeletal muscle. American Journal of Physiology 241 (Cell Physiology 10): C47–C54, 1981

    PubMed  CAS  Google Scholar 

  67. McMahon LF, Ryan MJ, Larson D, Fisher RL. Occult gastrointestinal blood loss in marathon runners. Annals of Internal Medicine 101: 846–847, 1984

    Google Scholar 

  68. Newhouse I. The effects of prelatent/latent iron deficiency on physical work capacity. Ph.D. Thesis, University of British Columbia, 1987

    Google Scholar 

  69. Nickerson HJ, Holubets M, Tripp AD, Pierce WE. Decreased iron stores in high school female runners. American Journal of Diseases of Children 139: 1115–1119, 1985

    PubMed  CAS  Google Scholar 

  70. Oertel J, Bombik BM, Stephan M, et al. Ferritin in bone marrow and serum in iron deficiency and iron overload. Blut 37: 113, 1978

    PubMed  CAS  Google Scholar 

  71. Ohira Y, Edgerton VR, Gardner GW, Gunawardena KA. Sinewirante B. Characteristics of blood gas in response to iron treatment and exercise in iron deficient and anemic subjects. Journal of Nutritional Science and Vitaminology 29: 129–139, 1983

    PubMed  CAS  Google Scholar 

  72. Ohira Y, Edgerton VR, Gardner GW, Gunawardena KA, Sinewirante B, et al. Work capacity after iron treatment as a function of hemoglobin and iron deficiency. Journal of Nutritional Science and Vitaminology 27: 87–96, 1981

    PubMed  CAS  Google Scholar 

  73. Ohira Y, Edgerton VR, Gardner GW, Sinewirante B, Barnard RJ, et al. Work capacity heart rate and blood lactate response to iron treatment. British Journal of Haematology 41: 365–372, 1979

    PubMed  CAS  Google Scholar 

  74. Ohira Y, Edgerton VR, Gardner GW, Sinewirante B, Simpson DR. Non hemoglobin related effects on heart rate in iron deficiency anemia. Nutrition Reports International 18 (6): 647–651, 1978

    CAS  Google Scholar 

  75. Pakarinen A. Ferritin in sports medicine. Nordilab Newsletters, 4: 20–28, 1980

    Google Scholar 

  76. Parr RB. Iron deficiency in female athletes. The Physician and Sports Medicine 12 (4): 81–86, 1984

    Google Scholar 

  77. Passmore R, Eastwood MA. Human nutrition and dietetics, pp. 121–126, Churchill Livingstone, Edingburgh, 1986

    Google Scholar 

  78. Pate RR, Maguire M, Wyk JV. Dietary iron supplementation in women athletes. Physician and Sports Medicine 7 (9): 81–88, 1979

    Google Scholar 

  79. Paulev PE, Jordal R, Pedersen NS. Dermal excretion of iron in intensely training athletes. Clinica Chimica Acta 127: 19–27, 1983

    CAS  Google Scholar 

  80. Plowman SA, McSwegin PC. The effect of iron supplementation on female cross country runners. Journal of Sports Medicine 21: 407, 1981

    CAS  Google Scholar 

  81. Porter AMW. Do some marathon runners bleed into the gut? British Medical Journal 287: 1427, 1983

    PubMed  CAS  Google Scholar 

  82. Potera C. Gastrointestinal bleeding found in long distance runners. Physician and Sports Medicine 12 (12): 29, 1984

    Google Scholar 

  83. Puhl JL, Runyan WS. Hematological variations during aerobic training of college women. Research Quarterly for Exercise and Sport 51 (3): 533–541. 1980

    PubMed  CAS  Google Scholar 

  84. Ruckman K, Sherman A. Effects of exercise on iron and copper metabolism in rats. Journal of Nutrition 111: 1593–1601, 1981

    PubMed  CAS  Google Scholar 

  85. Schoene RB, Escourrov P, Robertson HT, Nilson KL, Parsons JR, et al. Iron repletion decreases maximal exercise lactate concentrations in female athletes with minimal iron deficiency anemia. Journal of Laboratory and Clinical Medicine 102 (2): 306–312, 1983

    PubMed  CAS  Google Scholar 

  86. Selby GB, Eichner ER. Endurance swimming, intravascular hemolysis, anemia, and iron depletion: new perspective on athletes anemia. American Journal of Medicine 81: 791–794, 1986

    PubMed  CAS  Google Scholar 

  87. Shiraki K, Yoshimura H, Yamada T. Anemia during physical training and physical performances. In XXth World Congress in Sports Medicine Handbook, pp. 410–415, Federation Internationale de Medicine Sportive, 1974

    Google Scholar 

  88. Siegel A, Hennekens C, Solomin H, Vanboeck B. Exercise-related hematuria findings in a group of marathon runners. Journal of the American Medical Association 241 (4): 391–392, 1979

    PubMed  CAS  Google Scholar 

  89. Sumes MA, Refino C, Dallman PR. Manifestation of iron deficiency of various levels of dietary iron intake. American Journal of Clinical Nutrition 33: 570–574, 1980

    Google Scholar 

  90. Spriet LL, Gledhill N, Froese AB, Wilkes DL. Effect of graded erythrocythemia on cardiovascular and metabolic responses to exercise. Journal of Applied Physiology 61 (5): 1942–1948, 1986

    PubMed  CAS  Google Scholar 

  91. Steenkamp I, Fuller C, Graves J, Noekes TD, Jacobs P. Marathon running fails to influence RBC survival rates in iron-replete women. Physician and Sportsmedicine 14 (5): 89–95, 1986

    Google Scholar 

  92. Stewart JG, Ahlquist DA, McGill DB, Ilstrup DM, Schwartz S, et al. Gastrointestinal blood loss and anemia in runners. Annals of Internal Medicine 101: 843–845, 1984

    Google Scholar 

  93. Strause L, Hedgenauer J, Saltman P. Effects of exercise on iron metabolism in rats. Nutrition Research 3: 70–89, 1983

    Google Scholar 

  94. Valberg LB. Plasma ferritin concentration: their clinical significance and relevance to patient care. Canadian Medical Association Journal 122: 1240–1248, 1980

    PubMed  CAS  Google Scholar 

  95. Valberg LS, Sorbie J, Ludwig T, Pelletier D. Serum ferritin and the iron status of Canadians. Canadian Medical Association Journal 114: 417–421, 1976

    PubMed  CAS  Google Scholar 

  96. Vellar OD. Studies on sweat losses of nutrients: iron content of whole body sweat and its association with other sweat constituents, serum iron levels, hematological indices, body surface area, and sweat rate. Scandinavian Journal of Clinical Investigation 21: 157–167, 1968

    CAS  Google Scholar 

  97. Viteri FE, Torun B. Anemia and physical work capacity. Clinical Haematology 3: 609–626, 1974

    Google Scholar 

  98. Volpicelli NA. Effect of sports on the gastrointestinal tract and liver. In Appenzeller and Kinson (Eds) Sports medicine: fitness, training, injuries, 2nd ed., pp. 91–98, Urband and Schwarzenberg, Baltimore, 1983

    Google Scholar 

  99. Walters GO, Miller FM, Worwood M. Serum ferritin concentration and iron stores in normal subjects. Journal of Clinical Pathology 26: 770–772, 1973

    PubMed  CAS  Google Scholar 

  100. Williamson MR. Anemia in runners and other athletes. Physician and Sportsmedicine 9 (6): 73–79, 1981

    Google Scholar 

  101. Winick M. Beating iron deficiency anemia: a family physicians guide. Modern Medicine of Canada 36 (11): 1571–1581, 1981

    Google Scholar 

  102. Yoshimura H. Anemia during physical training (sports anemia). Nutrition Reviews 28 (10): 251–253, 1970

    PubMed  CAS  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to D. B. Clement.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Newhouse, I.J., Clement, D.B. Iron Status in Athletes. Sports Medicine 5, 337–352 (1988). https://doi.org/10.2165/00007256-198805060-00001

Download citation

Keywords

  • Ferritin
  • Iron Deficiency
  • Serum Ferritin
  • Iron Status
  • Work Capacity