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SPECIAL COMMUNICATIONS: Letters to the Editor-in-Chief

Routine Screening for Iron Deficiency Is an Important Component of Athlete Care

Chapman, Robert F.; Sinex, Jacob; Wilber, Randall; Kendig, Alicia; Moreau, Bill; Nabhan, Dustin; Stray-Gundersen, James

Author Information
Medicine & Science in Sports & Exercise: November 2017 - Volume 49 - Issue 11 - p 2364
doi: 10.1249/MSS.0000000000001358
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Dear Editor-in-Chief,

We read with interest the article “Iron Deficiency and Anemia among Collegiate Athletes: A Retrospective Chart Review” by Parks and colleagues (6). In our roles administering sports medicine and science activities within various US sport governing bodies, we hoped the results would provide clear evidence-based guidance regarding current practices of routine and regular screening for iron deficiency for competitive athletes across a range of sports. However, we feel that the authors’ conclusion suggesting that “given the high costs of testing, screening practices at each institution should be thoughtfully selected and routinely reassessed” is not appropriate given the limitations inherent in their analysis, the existing literature supporting iron status monitoring, and the complete cost–benefit ratio for athletes and their universities.

Many researchers and clinicians in sports medicine practice have come to the realization that normative blood chemistry values, particularly for serum ferritin, within highly trained athletes, may be substantially different than overall population norms [e.g., reviews in (1,2,8)]. Parks and colleagues used a serum ferritin of 20 ng·mL−1 as a lower range value to denote iron deficiency. However, a number of reviews have indicated that a more appropriate serum ferritin criterion value for athletes is 35 ng·mL−1 [e.g., (4,5)], and using this cutoff, Parks et al.’s own data indicate more than twice the number of low values for women (already at 30.8% with a 20 ng·mL−1 cutoff) and over five times more low values for men. We see high clinical value in a simple blood test to potentially catch iron deficiency issues in approximately 60% of female athletes and 25% of male athletes.

The authors suggest the financial cost of routine screening of CBC and ferritin may not be justified, relative to the number of anemic and iron deficient athletes that would be identified. Their recommendation is based partly on 2002 to 2014 costs charged by their university’s hospital laboratory of up to US $192 per individual. These costs seem grossly inflated compared with current prevailing rates, considering that individuals can self-order a serum ferritin test online through multiple providers for about US $40. Even at the higher costs the authors quoted, this expense is quite small when judged against the overall financial cost of supporting a university athlete (e.g., scholarship, competitive travel, coaching salaries). Attempting to minimize the cost of screening, as the authors suggest, through nutritional education or blanket iron supplementation without an actual measure of iron status is misguided.

Most importantly, there are well-established links between iron levels, total hemoglobin mass, maximal oxygen uptake, and aerobic exercise performance (1,7). Iron serves as an important component of cytochrome function, and iron depletion even without anemia can significantly worsen exercise performance (3). Considering the substantial time and effort invested by athletes in training for sporting achievement, the tens of thousands of dollars that can be invested yearly in supporting the training of a collegiate athlete, and the well-established importance of iron status on aerobic capacity, exercise training, and competitive performance across a wide range of sports, we strongly suggest that routine screening of hemoglobin concentration, iron screening, and appropriate iron supplementation regimens should be part of an overall strategy to support athlete health and athletic performance. Even the authors’ own data, viewed in this light, would suggest that the benefit to the athlete is well worth the cost.

Robert F. Chapman

Jacob Sinex

Department of Kinesiology

Indiana University

Bloomington, IN

Randall Wilber

Alicia Kendig

Bill Moreau

Dustin Nabhan

United States Olympic Committee

Colorado Springs, CO

James Stray-Gundersen

US Ski and Snowboard Association

Park City, UT

REFERENCES

1. Chatard JC, Mujika I, Guy C, Lacour JR. Anaemia and iron deficiency in athletes. Practical recommendations for treatment. Sports Med. 1999;27(4):229–40.
2. Clement D, Sawchuk L. Iron status and sports performance. Sports Med. 1984;1(1):65–74.
3. DellaValle DM, Haas JD. Impact of iron depletion without anemia on performance in trained endurance athletes at the beginning of a training season: a study of female collegiate rowers. Int J Sport Nutr Exerc Metab. 2011;21(6):501–6.
4. Govus AD, Garvican-Lewis LA, Abbiss CR, Peeling P, Gore CJ. Pre-altitude serum ferritin levels and daily oral iron supplement dose mediate iron parameter and hemoglobin mass responses to altitude exposure. PLoS One. 2015;10(8):e0135120.
5. Nielsen P, Nachtigall D. Iron supplementation in athletes. Sports Med. 1998;26(4):207–16.
6. Parks RB, Hetzel SJ, Brooks MA. Iron deficiency and anemia among collegiate athletes: a retrospective chart review. Med Sci Sports Exerc. 2017;49(8):1711–5.
7. Schmidt W, Prommer N. Impact of alterations in total hemoglobin mass on VO 2max. Exerc Sport Sci Rev. 2010;38(2):68–75.
8. Szygula Z. Erythrocytic system under the influence of physical exercise and training. Sports Med. 1990;10(3):181–97.
© 2017 American College of Sports Medicine