What is Role of Iron Supplementation in Non-Anemic Endurance Athletes?

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It is relatively common to have young endurance athletes come into my office requesting lab work to check for anemia (low red cell counts) and iron stores in hopes of finding a relatively straight-forward treatment for fatigue or low performance. While the prevailing trends in the sports medicine literature are more in favor of iron supplementation,  I must also bear caution that iron treatments alone are not a "magic bullet" and that more specific review of training regime, diet, and sleep patterns is absolutely essential.

There is no doubt that endurance athletes are at particular risk for anemia, Potential exercise-related causes include iron losses through sweat, stool and urine along with breakdown of red cells with foot impact against the ground in running. Concerns about the role of chronic training-related inflammation reducing general body iron absorption and recycling and a diet deficient in adequate iron intake may also compound the issue.

We may also hold a higher expectation for red cell count numbers in endurance athletes, and this bias creates more findings of relative anemia. Red cell levels that are in the low normal range may be fine for the less active or couch potatoes of the world, but may not be as acceptable for a higher level runner, swimmer or cyclist.

Over the past 5-10 years, I have definitely seen a movement among athletes, coaches and sports medicine experts to be more apt to recommend iron supplementation for endurance athletes who have low iron stores but who are not be anemic (have low red cell counts). Prior to that time, the prevailing thought was to favor iron treatments only for those athletes who were both anemic and having lower iron stores.  The results of a recent meta-analysis in the British Journal of Sports Medicine lend additional support that iron supplementation for low iron stores without frank anemia can improve iron status and aerobic capacity.

Interesting points discussed in the article that may further influence treatment recommendations include:

• Selecting appropriate markers to measure iron status-  serum ferritin (measure of body iron stores) can vary from day-to-day and in combination with iron saturation studies, both tests may not be adequate to reflect whole body iron status. Use of soluble transferrin receptor studies may be more accurate, though variations in lab techniques may limit comparisons of findings over time.
• Higher doses of iron supplementation over a shorter period of time were suggested to be more effective than smaller doses over longer periods with effect on iron stores to be diminished with a treatment period over 80 days. 
• Optimal dosing amounts, protocols, and routes (oral versus injected) require more study.
• Female endurance athletes may respond differently to treatment, most likely due to menstrual cycle variations on hormonal levels that may influence iron absorption.

While this information adds significant value to the measurement and treatment of iron issues in endurance athletes, it is crucial to recognize that focusing on iron alone is grossly simplistic and insufficient when evaluating performance issues in endurance athletes.

A comprehensive review of diet may reveal insufficient overall caloric intake as high level athletes often suffer from relative energy availability issues where training related caloric demands may not be met by food intake. I have often found that lower calorie diets often have low intake high protein foods such as meat. poultry, fish, and dairy sources that not only reduce intake of high level, easily absorbed iron sources (red meat, red fish, dark poultry, veal) but also essential calcium (dairy) and the protein stores needed for muscle growth and recovery (especially if ingested within 30 minutes after exercise).

Diet choices that help reduce inflammation can not only aid in absorption of essential nutritional elements, but also minimize joint stiffness, muscle soreness, and reduction in mental sharpness, Less processed foods, lower carbohydrate diets, and diets rich in items such as berries and cherries, fish and fish oils, and spices such as tumeric and ginger are recommended as part of an anti-inflammatory diet.

Inadequate sleep can also lead to inadequate performance. Emerging evidence suggests that a minimum of 8.5 hours a day (can include a short nap of no more than an hour) can reduce risk of injury, illness, and may also contribute to enhanced academic and athletic performance. Sleep is part of the overall recovery process that must be integrated into a thoughtful training program that feature adequate rest days and alternating periods of heavier and easier training that may have to be individualized for each athlete.

Fatigue and under-performance are common concerns in the endurance athletes and human nature often leads us to find convenient remedies. Findings that support iron supplementation in non-anemic athletes give some evidence-based measures of optimism, but must be tempered with the reality that more comprehensive evaluation is necessary to provide optimal outcomes. Seeking counsel from a sports medicine expert versed in training and performance concerns of endurance athletes is a sensible and often very productive step in enhancing overall health.

Peak Athletic Performance Often Leads to Peak Illness Risk

It can be an awesome feeling to be "in the zone" or "performing better than I have in years”.

It however, can be a major downer when that peak performance comes at a cost to immediate health and the immune system. 

Anyone who has been around the time of a big show knows how performers like to celebrate afterward. That's right- everyone tends to get sick.

Exchange the big show for the big race or big competition and you often see the same outcome- many athletes go from the podium or finish line to the sick bed. Saw it at the Olympics where my first up close and personal views of gold, silver and bronze medals were around the necks of athletes coming in to the medical unit for upper respiratory infection evaluations. 

Those were the fortunate ones who had timed their peak performance to occur at the Games and didn't have unplanned illness interrupt training or competition.

Unfortunately, many times this fairly tale ending doesn't occur. Peak performance earlier in a season leads to mid-season illness and eventual disappointment. Solid evidence tells us that moderate levels of physical exertion are protective against illness, while higher extremes of activity can diminish immune defenses and increase illness risk. Having a solid base of fitness before assuming more rigorous training can also reduce risk of diminished immunity and increased chance of illness.

It is nearly impossible to maintain peak performance for too long, especially over a schedule of multiple events combined with the stressors of school, homework, and a social life. 

Trying to get adequate sleep (minimum 8 hours a night), proper nutrition including berries, cherries, and fish for the anti-inflammatory effect, and planned off days from training and competition can help combat the stressors that sap performance.

More important is adhering to the principles of periodization, where well-constructed training blocks are created to allow peaking at optimal times while also maintaining periods of relative rest and recovery.

So, if an athlete tells me "I'm at my best" right before a chosen high level competition, then less cause for concern. Still might get sick afterward, but the merging of preparation and schedule hopefully is fairly favorable.

If an athlete is peaking well before that big competition which is still weeks or months away or with many of my young athletes when they have to get up every week because "every game is a big game", then my worry starts to go up.

Nothing worse than showing up in the doctor's office missing key training days or even worse, important competition time due to illness. Enhancing the immune system with proper rest and recovery can lead to more visits in the winner's circle and less time scheduling visits with the medical staff.

Highlights: Unique Challenges of Adolescent Performing Artist

 Thanks to the Chapman University College of Performing Arts and the Performing Arts Medicine Association for hosting the 4th annual Healthy Approaches to the Training of Performing Artists Conference last weekend.  Presented on Unique Challenges of the Adolescent Performer and will highlight key points below:

Teenagers Not Designed as Early Birds: How to Combat Adolescent Sleep Deprivation

Are you a well-meaning coach trying to get the most out of your athletes during early morning training sessions? Somewhat frustrated that everyone seems a step slow or out of sorts during zero period? While "morning people" are a dime a dozen in the adult world, doesn't it seem that finding teenagers raring to go at 0600 is like the proverbial needle in a haystack?

According to a timely American Academy of Pediatrics (AAP) policy statement on School Start Times for Adolescents this type of behavior is not just an irritating by-product of teenage rebellion and striving for independence, but is a consequence of age-related delays in release of melatonin (hormone that influences sleep onset) and a slower drive to fall asleep compared with non-adolescents.

So yes, teenagers are biologically designed to have their own (circadian) rhythms and if they truly ran the world (instead of thinking that they do) they would select later school start times around the order of 8:30 if not later. This does often conflict with the usual norms of the adult-oriented world (such as parents having to be at work by 9 AM) and the realities of limited access to pools and court space along with trying to fit in another activity into already tight class schedules.

The ultimate goal according to the AAP and its review of the scientific literature would be to provide a consistent 8.5-9.5 hours of sleep per night and reduce the consequences of cumulative sleep deprivation:

• as has been outlined in this blog before, sleep deprivation may contribute to increased injury risk and decreased athletic and academic performance
• sleep deprivation may cause or modulate acute and chronic pain responses
• sleep deprivation may decrease overall immunity and increase risk of infection or illness
• chronic sleep loss may increase risk of obesity and diabetes

How do we best respond to these sleep deprivation concerns?

First of all, don't think that teenagers shouldn't get off without taking some responsibility for their less than impressive sleep statistics, as they often do not do themselves any favors with poor sleep initiation behaviors such as late night caffeine use, using electronics and media right before bedtime, and having access to television in bedrooms. Modifying some of these habits definitely could should be a high priority for parents, coaches, and educators with emphasis on the importance of sleep in post-activity recovery, preparation for next day activity, and especially the impact of insufficient sleep in mood and academic focus:

While giving appropriate counsel to sleep hygiene behaviors, there are certain nutritional recommendations that may also increase the quality of sleep initiation and maintenance according to an article conveniently published just before the AAP article:

• High Glycemic Index foods such as white rice, pasta, bread, and potatoes may promote sleep; however, they should be consumed more than 1 hour before bedtime.
• Diets high in carbohydrate may result in shorter sleep latencies.
• Diets high in protein may result in improved sleep quality.
• Diets high in fat may negatively influence total sleep time.
• When total caloric intake is decreased, sleep quality may be disturbed.
• Small doses of tryptophan (1 gram) may improve both sleep latency and sleep quality. This can be achieved by consuming approximately 300 grams of turkey or approximately 200 grams of pumpkin seeds.
• The hormone melatonin and foods that have a high melatonin concentration may decrease sleep onset time.

Promoting short naps (under a hour) during the day can contribute to the overall daily sleep total, and if done before an afternoon or evening exercise session may contribute to reduced sleepiness and and can be beneficial when learning new skills, strategies or techniques.

Finally, those of schedule-making adults might want to take a hard and scientific look at the utility of early-morning activities designed for adolescents. While the decision for later school starts may not be part of your pay grade, carefully weighing the risks and benefits of zero period weight training sessions or other before school activities in favor of more after school activities may actually increase athletic and academic performance in this age group. Delaying the start of afternoon training or competition sessions to allow for that brief nap (again, under an hour) may also enhance overall performance and mood of the team or group.

Do these sound like sensible and realistic recommendations to address sleep issues in adolescents?