IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

In female athletes how does iron supplementation compared to no intervention, influence

prevention of anemia and improved performance over 3 months?
Katrin Larusson
University of New Hampshire

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

Abstract
This paper explores five published articles that report on research conducted on iron
supplementation in female athletes and its influence in the prevention of iron deficiency leading
to anemia. The articles also analyzed iron supplementation impact of physical performance. The
clinical recommendation that healthcare providers need to be well educated on the risks,
prevention and treatment of iron deficiency in the population of female athletes was determined
through the analysis of the research articles selected.

Keywords: female athletes, iron supplementation, exercise induced anemia, iron deficiency

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

PICO Question
In female athletes, how does iron supplementation compared to no intervention, influence
prevention of anemia and improved performance over 3 months?
Reasoning
Female athletes are at an increased risk for iron deficiency anemia due to several factors.
Insufficient iron intake, along with loss of iron through heavy physical activity leading to
mechanical hemolysis, and an increased loss of iron through sweat and menstruation are all
contributing factors of iron deficiency anemia (IDA). Iron deficiency has a profound effect on
cognitive and physical function. According to Santolo, et al. (2008), anemia is particularly
detrimental for athletes because impairment of blood gas transport may decrease physical work
capacity and may be a reason for fatigue, weakness, and dizziness. Early identification of iron
deficiency can prevent the development of anemia and need for supplementation, and improve
performance outcomes. Healthcare providers need to be educated on the increased risk of iron
deficiency in female athletes as well as side effects of iron supplementation. The 3-month time
frame was selected because it is the estimated time needed for full iron repletion with oral iron
supplementation. However, several of the articles utilized a 6-week trial period, which was found
to be effective in preventing anemia. Nurses will be instrumental in identifying early indicators
of iron deficiency or risk factors exhibited by female patients. Through analyzing five articles, a
better understanding of iron supplementation and its benefits and limits for female athletes will
be better understood.

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

Search Methods
A total of three databases were searched with several key terms. After applying the
selected inclusion and exclusion criteria, five articles were selected to be reviewed. CINHAL
was searched using the Boolean/phrase search mode with the key words female athletes and iron
deficiency with the limits of English and between the years of 2005 and 2015, 19 articles were
found. To further identify relevant articles, iron supplementation was added to the key words.
Using the same search mode and limits with the key words, female athletes and iron deficiency
and supplementation, a total of 5 results were found with 4 relevant articles. Then the Cochrane
Central Register of Controlled Trails database was searched using the Boolean/phrase search
mode with the key words female athletes and iron deficiency and supplementation with the limits
of English and between the years of 2005 and 2015, and a total of 3 articles with 2 useful
articles, one of which was found in an earlier search. The Cochran Database of Systematic
Reviews was also searched with several different terms with unsuccessful results. A total of five
articles were found to be applicable to the previously stated question, with several additional
articles used to better understand iron deficiency due to physical exercise and the variety of
blood tests done to collect data.
Evidence Analysis
The article Effect of iron injections on aerobic-exercise performance of iron-depleted
female athletes by Peeling et al., (2007) analyzed the use of intramuscular iron supplementation
in iron depleted female athletes in comparison to a placebo group with the use of several blood
tests and three exercise tests. A total of 16 women were selected after exclusion and inclusion
criteria were implemented; some of this criteria included current health status, with no recent
history of iron therapy or blood donation. The women completed a base line of the three exercise

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

tests, a VO2max test, and a timed test to exhaustion at VO2max workload before treatment along
with a blood test. Participants were randomly placed in a placebo group or treatment group. The
treatment consisted of 2ml of intramuscular iron (Ferrum H), to the upper quadrant of gluteus
maximus over a 10 day period. The placebo group received normal saline. Study participants
were retested with both the blood and exercise tests 20 days after the first injection and again 28
days after the first injection. The results found that intramuscular injections effectively increase
serum ferritin levels but minimally enhanced submaximal or maximal aerobic exercise
performance. To consider all aspects of female athletes the study took into consideration the
participants menstruation cycle and dietary iron intake. Several weaknesses found were the
participants varied choice in the method of performing the exercise tests and a short duration of
tests. It is possible that the beneficial effects of iron supplementation on exercise economy
occur as the intensity and duration of exercise increases, and therefore a 10-minute steady-state
submaximal exercise test at ~70% VO2max might not be specific enough to detect performanceeconomy changes (Peeling et. al, 2007). Iron aids in the delivery and utilization of oxygen,
which is essential for optimal physical performance. More research is needed to conclude if
intramuscular iron supplementation could increase serum ferritin along performance
enhancement.

Monitoring recovery from iron deficiency using total hemoglobin mass by Wachsmutch
et al. (2015) collected data from 30 female recreation athletes ages 19-41, with 22 women found
to be iron depleted and 8 with normal ferritin levels who formed the control group. The exclusion
criteria included no iron supplementation at least 3 months prior to the start of the study. The
iron-depleted group was given oral iron at 100 mg of Ferro Sanol Duodenal for 10 weeks. If

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

ferritin values still remained low additional supplementation for 4-8 weeks was implemented.
Blood tests and VO2max tests on the bike were completed at the start and end of the study, with
additional tests done at 3 weeks, 5 weeks, and 8 weeks throughout the study. Data was collected
again post iron supplementation at 4 weeks and 12 weeks, with a total of 22 weeks of data
collected from both groups. At the end of the iron supplementation, ferritin concentration and all
other markers of iron status were normal and did not differ from the control group. Hemoglobin
mass significantly increased during supplementation and remained elevated for the following 12
weeks. VO2max clearly increased by 7.4%, which is consistent with previous data and was
closely related to the elevated Hbmass (Wachsmutch et al. 2015). The studys limitations
included the lack of monitoring of menstrual blood loss, dietary intake of iron and extent of
exercise. The study concluded that hemoglobin mass along with hemoglobin and ferritin
measurements should be used to help detect iron deficiency earlier. Because ferritin and
hemoglobin can be influenced easily by inflammation, acute exercise and hydration status,
identifying additional markers of iron deficiency can help prevent female athletes from
progressing to iron deficiency anemia.

Randomized, double blind, placebo-controlled trial of iron supplementation in female

soldiers during military training: effects on iron status, physical performance, and mood by
McClung et. al (2009) analyzed female soldiers during training. While this study did not
specifically look at female athletes, the military personal were currently enrolled in basic combat
training, which is physically demanding and equivocal to a female athlete. The study was a
randomized, double blind placebo-controlled study in which 171 female military personal with
the mean age of 21 were enrolled. The goal of the study was to prevent a decrease in iron status

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

during 8 weeks of military training. The placebo group received a cellulose capsule and the
control group received 100mg of ferrous sulfate every morning, provided by a blinded volunteer.
At the end of the 8 weeks a two-mile run was completed with no significant difference found
between the two groups. Using the Profile of Mood States questionnaire a pre and post treatment
test was conducted with a slight increase of mood in the group receiving the iron supplement,
specifically with improved vigor. When looking at blood tests after treatment, the placebo group
had diminished serum ferritin and all were identified as iron deficient. The iron supplement
group showed an elevation of hemoglobin and red blood cell distribution width and sTfR
indicating that the study had achieved the goal and prevented the control group from developing
iron deficiency during the 8-week basic training. Unfortunately, the study did not conduct a pre
two-mile run test in which to compare the post treatment results. The researchers did not factor
or evaluate menstruation or dietary intake. It was concluded that iron supplementation was able
to improve cognitive vigor, and prevent the development of iron deficiency. In the future the
researchers would like to analyze dietary intake of iron of female military personal and provide
further education for females on base.

The study Iron supplementation improves energetic efficiency in iron-depleted female

rowers by Diane Dellavalle and Jere Hass (2014) completed a 6 week randomized double blind
placebo-control with 48 collegiate rowers from five different universities who were identified as
non-anemic prior to participation. The control group was given 50 mg of FeSO4 twice a day and
instructed to take one capsule with their morning meal and the second with their evening meal.
The placebo group was given the same instructions and an identical red capsule with lactose. The
researchers had the participants record their menstrual status, eating habits and physical activity

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

in daily training logs. Physical testing on a Concept2 rower was used to measure participants
VO2 along with non-fasting venous blood samples before and after treatment. Only 31 rowers
completed the study due to health and/or personal reasons unrelated to the study. After 6 weeks
of iron supplementation significant effects were observed in hemoglobin levels and moderate
effects of serum ferritin, but no major difference was found between the two groups VO2 4 km
time trial. However the researches noticed a lack of compliance in both groups, more
significantly in the iron control group. It was noted that the more supplement that was
consumed in the Fe group, the greater positive change in gross efficiency after 6 weeks of
training and treatment (Dellavalle and Hass, 2014). The group that consumed the iron
supplement decreased their oxygen consumption by 5% and slowed their lactate response during
the post 4 km time trial. It was concluded that iron levels could be significantly increased in 6
weeks with iron supplementation. More research for an extended period of time with better
control is needed to analyze the benefits of iron supplementation on exercise performance in
female athletes.

The final article selected Iron supplementation for female athletes: Effects on iron status
and performance outcomes by Diane Dellavalle (2013) was a review of the effects of iron
supplementation on iron status and performance in active women. While the article did not
conduct any research, it reported on the effects of oral iron supplementation. The article touched
on iron overload and advocated for better screening methods to identify iron deficiency in at risk
female athletes. Dellavalle discussed the differences in opinions regarding how much iron
supplementation should be proscribed and at what level or iron deficiency supplementation
should be implemented. The article concluded that female athletes should be regularly screened

IN FEMALE ATHLETES AND IRON SUPPLEMENTATION

for iron deficiency using hemoglobin and serum ferritin along with more substantial education
about dietary intake for at risk patients.
Synthesis
Female athletes are at an increased risk for iron deficiency due to increased body turnover
of iron and loss of iron through sweat, gastrointestinal bleeding, menstruation, and inflammation
related to high impact of endurance exercise. Iron is essential for the delivery and utilization of
oxygen, which in turn impacts physical performance. According to Peeling et al. (2007),
intramuscular iron supplementation is an adequate way to rapidly increase serum ferritin levels
in athletes. Several other research articles concluded that oral iron supplementation was effective
in decreasing the development of iron deficiency and improving oxygen utilization, resulting in
improved performances. Oral supplementation requires a longer treatment time, but is effective.
McClung et al. (2009) showed that iron supplementation improved cognitive vigor and prevented
the development of iron deficiency. An argument was made to include hemoglobin mass in the
screening for iron deficiency leading to anemia. All the articles analyzed indicated that further
research into the effects of long-term iron supplementation and increased iron screening as an
effort to prevent iron deficiency was needed. Iron supplementation for 6-weeks or more
compared to no intervention has been indicated to prevent anemia and thus improve physical
performance.
Clinical Recommendation
Based on the findings from this research analysis, it is important to note that iron
supplementation is an effective method for the prevention of iron deficiency and anemia in highrisk patients such as female athletes. Female athletes are at an increased risk for developing iron

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deficiency due to several factors previously discussed. It is important for healthcare providers to
be well educated on the risks, prevention, and treatment of iron deficiency in the population of
female athletes, regardless of their level of experience. The results showed that oral and
intramuscular iron supplements were effective in the prevention or treatment of iron deficiency
with at least 2 weeks needed for effective results to be found (3 months recommended). It should
be noted for future nursing practice that iron screening should be conducted routinely for female
athletes, especially for those who are taking iron supplements, in order to determine the
effectiveness of treatment and to prevent iron overload. Further research is needed to determine
the best method of testing iron levels; hemoglobin mass has been newly researched as an
indicator for iron deficiency. Dietary intake of iron is another possible aspect of IDA that could
benefit from more research. To ensure the best health and performance of female athletes,
additional education must be provided to patients regarding the risk and prevention of iron
deficiency.

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References
Bass, L. J., & McClung, J. P. (2011). Iron Nutrition and the Female Athlete: Countermeasures
for the Prevention of Poor Iron Status. Journal Of Evidence-Based Complementary &
Alternative Medicine, 16(3), 195-2006p. doi:10.1177/2156587211401747
Dellavalle, D. M., & Haas, J. D. (2014). Iron Supplementation Improves Energetic Efficiency in
Iron-Depleted Female Rowers. Medicine & Science In Sports & Exercise, 46(6), 12041215. doi:10.1249/MSS.0000000000000208
Dellavalle, D. M. (2013). Iron supplementation for female athletes: effects on iron status and
performance outcomes. Current Sports Medicine Reports (American College Of Sports
Medicine), 12(4), 234-239 6p. doi:10.1249/JSR.0b013e31829a6f6b
Di Santolo, M., Stel, G., Banfi, G., Gonano, F., & Cauci, S. (2008). Anemia and iron status in
young fertile non-professional female athletes. European Journal Of Applied Physiology,
102(6), 703-709. doi:10.1007/s00421-007-0647-9
McClung, J., Karl, J., Cable, S., Williams, K., Nindl, B., Young, A., & Lieberman, H. (2009).
Randomized, double blind, placebo-controlled trial of iron supplementation in female
soldiers during military training: effects on iron status, physical performance, and mood.
American Journal Of Clinical Nutrition, 90(1), 124-131 8p. doi:10.3945/ajcn.2009.27774
Peeling, P., Blee, T., Goodman, C., Dawson, B., Claydon, G., Beilby, J., & Prins, A. (2007).
Effect of iron injections on aerobic-exercise performance of iron-depleted female
athletes. International Journal Of Sport Nutrition And Exercise Metabolism, 17(3), 221231.

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Wachsmuth, N. B., Aigner, T., VLzke, C., Zapf, J., & Schmidt, W. F. (2015). Monitoring
Recovery from Iron Deficiency Using Total Hemoglobin Mass. Medicine & Science In
Sports & Exercise, 47(2), 419-427 9p. doi:10.1249/MSS.0000000000000420

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