By, Dr. David Carfagno


Iron deficiency anemia (IDA) is a prevalent condition among athletes, impacting their performance and overall health. Athletes, due to their increased iron requirements, are particularly vulnerable to this condition. In this review, we will discuss the workup of iron deficiency anemia in athletes, including the diagnostic criteria, causes, and treatment options.

**Diagnostic Criteria:**

1. **Hemoglobin and Hematocrit Levels:**
   – One of the primary diagnostic criteria for IDA is a low hemoglobin (Hb) level, typically less than 13.5 g/dL for males and less than 12.0 g/dL for females.
   – A reduced hematocrit (Hct) level, often less than 38.3% for males and less than 36.0% for females, can also indicate IDA.

2. **Serum Ferritin Levels:**
   – Serum ferritin is a crucial biomarker for IDA diagnosis. A level below 30 ng/mL is often indicative of depleted iron stores.

3. **Transferrin Saturation (TSAT):**
   – A low TSAT, usually below 16%, suggests insufficient iron transport and is supportive of an IDA diagnosis.

**Causes of Iron Deficiency Anemia in Athletes:**

1. **Increased Iron Losses:**
   – Athletes may experience elevated iron losses through sweat, urine, and gastrointestinal bleeding, especially in long-distance runners or those engaged in high-intensity training.

2. **Inadequate Dietary Iron Intake:**
   – Many athletes fail to meet their increased iron requirements through diet alone. Vegetarian or vegan athletes may be at higher risk due to lower heme iron intake.

3. **Menstrual Blood Loss:**
   – Female athletes often experience significant menstrual blood loss, further increasing their susceptibility to IDA.

4. **Gastrointestinal Disorders:**
   – Gastrointestinal disorders like celiac disease, inflammatory bowel disease, or Helicobacter pylori infection can impair iron absorption in athletes.

5. **Foot Strike Hemolysis:**
   – Repetitive foot strike during activities like long-distance running can cause hemolysis, leading to the release of iron from red blood cells.

**Workup and Evaluation:**

1. **Medical History and Symptoms Assessment:**
   – Begin with a detailed medical history, paying attention to fatigue, pallor, shortness of breath, and any gastrointestinal symptoms.

2. **Physical Examination:**
   – Conduct a thorough physical examination, including a check for pallor, conjunctival pallor, and clubbing.

3. **Laboratory Tests:**
   – Perform complete blood count (CBC) to assess hemoglobin and hematocrit levels.
   – Measure serum ferritin, transferrin saturation, and iron levels to confirm iron deficiency.
   – Check for other markers such as red blood cell distribution width (RDW) and mean corpuscular volume (MCV).

4. **Gastrointestinal Evaluation:**
   – If indicated, consider endoscopy and colonoscopy to rule out gastrointestinal bleeding sources.

**Treatment Options:**

1. **Oral Iron Supplementation:**
   – Prescribe oral iron supplements such as ferrous sulfate, ferrous fumarate, or ferrous gluconate.
   – Administer with vitamin C to enhance iron absorption.
   – Monitor for side effects, such as gastrointestinal discomfort.

2. **Intravenous Iron Therapy:**
   – Consider intravenous iron therapy for athletes with severe iron deficiency or poor oral iron tolerance.

3. **Dietary Modification:**
   – Emphasize iron-rich foods, including lean meats, fish, poultry, legumes, and fortified cereals.
   – Encourage a balanced diet with adequate calorie intake to support training and recovery.

4. **Menstrual Management:**
   – Provide education and support for female athletes to manage menstrual blood loss.

5. **Training Modification:**
   – Adjust training intensity and volume to reduce excessive iron losses through hemolysis.


Iron deficiency anemia is a prevalent condition among athletes, impacting their performance and overall health. Timely diagnosis and appropriate management are essential for their well-being. By understanding the diagnostic criteria, causes, and treatment options discussed in this review, healthcare professionals can effectively work up and address iron deficiency anemia in athletes.


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