Anemia in Sports: A Narrative Review

Recent years have brought about new understandings regarding the pathogenesis of anemia in sports. From hemodilution and redistribution considered to contribute to the so-called “sports anemia” to iron deficiency caused by increased demands, dietary restrictions, decreased absorption, increased losses, hemolysis, and sequestration, to genetic determinants of different types of anemia (some related to sport), the anemia in athletes deserves a careful and multifactorial approach. Dietary factors that reduce iron absorption (e.g., phytate, polyphenols) and that augment iron’s bioavailability (e.g., ascorbic acid) should be considered. Celiac disease, more prevalent in female athletes, may underlie an unexplained iron deficiency anemia. Iron loss during exercise occurs in several ways: sweating, hematuria, gastrointestinal bleeding, inflammation, and intravascular and extravascular hemolysis. From a practical point of view, assessing iron status, especially in the athletes at risk for iron deficiency (females, adolescents, in sports with dietary restrictions, etc.), may improve the iron balance and possibly the performance. Hemoglobin and serum ferritin are measures that are easily employable for the evaluation of patients’ iron status. Cutoff values should probably be further assessed with respect to the sex, age, and type of sport. A healthy gut microbiome influences the iron status. Athletes at risk of iron deficiency should perform non-weight-bearing, low-intensity sports to avoid inducing hemolysis.

The Role of an Innovative Liposomal Form of Iron Pyrophosphate in the Correction of Oxygen Transfer Disorders in Representatives of Olympic Cyclic Sports

Today, sports anemia occurs in elite sports quite often, although it is not a disease (does not apply to ICD-10), but only a pathological condition. Sports anemia is characterized by changes in the red link of the blood, and it is associated with a decrease in the content of erythrocytes and / or hemoglobin. However, this condition leads to a significant decrease in physical performance, and, consequently, the effectiveness of the competitive activity of representatives, first of all, of cyclic sports. Athletes are more sensitive to the effects of anemia and iron deficiency than people who are not constantly exposed to intense physical activity, since performance depends on the maximum oxygen consumption and utilization of active muscles. Sports anemia is often iron deficient, as well as B12 and folate deficient. Therefore, the assessment of various factors accompanying the development of anemia and the development of technologies for the correction of this pathological condition is an important task of sports laboratory diagnostics, as well as pharmacology and nutritional science of sports. Material and methods. We conducted a randomized, double-blind, placebo-controlled study to assess the safety and effectiveness of the effect of a course use of the Santeferra dietary supplement containing liposomal ferric iron in the form of pyrophosphate, vitamins B9, B12 and ascorbic acid on the results of training activities of representatives of cyclic sports with predominantly an aerobic energy supply mechanism. In the course of a dynamic study, which lasted 60 days, the parameters of hematological homeostasis and accumulation, metabolism and transport of iron (content of serum iron, transferrin, ferritin, folic acid, iron binding capacity of serum, saturation of transferrin with iron), as well as the level of serum erythropoietin and the severity of oxidative stress were assessed directly in the membranes of erythrocytes. In parallel, we determined the indicators of aerobic endurance: the absolute and relative values of the maximum oxygen consumption and the PWC170 value. Results and discussion. We found out that in the study sample of 67 athletes who specialized in sports with aerobic energy supply (running disciplines of athletics, rowing and canoeing, triathlon, cross-country skiing), 19 (28.35%) had manifestations of sports anemia, and 23 (34.32%) had latent iron deficiency, which also negatively effect on their physical performance. The course application of Santefrerra, 1 capsule per day for 60 days, helped to normalize the accumulation, transport and metabolism of iron, as well as to significantly reduce the manifestations of oxidative stress that occurs under the influence of prolonged physical exertion. In athletes with anemia and latent iron deficiency, practically no changes in the content of erythropoietin in the blood serum were found. At the end of the course of taking a dietary supplement, the indicators of the relative maximum oxygen consumption in the athletes of the main group increased by 11.5% (P <0.05) and the results of the PWC170 test by 11.4% (P <0.05) which displays predominantly aerobic endurance. In the placebo-control groups, we noted no positive dynamics in indicators of the red link of hematological homeostasis and the accumulation, metabolism and transport of iron, as well as the parameters of the prooxidant-antioxidant balance directly in the erythrocyte membranes during the 60-day observation period. Indicators of aerobic endurance also remained unchanged. Conclusion. Thus, the course using Santeferra is not accompanied by the development of side effects and is effective for the treatment of iron deficiencies in athletes

Reference Change Values for Immature Red Blood Cell Parameters in Under-20 Soccer Players

Introduction: Immature red blood cell parameters compose of the anti-doping programs of several sports, including soccer. The biological variability of reticulocytes is not well defined in young athletes. Our aim was to calculate biological variation and reference change values (RCV) for immature red blood cell parameters in young soccer players.Methods: Samples from 19 male soccer players (mean age, 18 ± 1 years) were collected before the start of training (C0) and after two (C1) and four weeks of training. Blood samples were collected in tubes with K3-EDTA Vaccuete® (Greiner Bio-One). Red blood cell parameters were analyzed on Sysmex XE-5000®. The e-Check Sysmex® 2 levels were used to obtain the coefficient of analytical variation (CVA). Homogeneity of variance was verified using the Cochran test. The within-subject (CVI) and between-subject biological variation (CVG) was calculated according to the mean and standard deviation from the athletes’ results. ANOVA with repeated measures was used to compare the means at the significance level of p<0.05. RCV95% was calculated using the Fraser’s formula: RCV=21/2 x1.96x(CVA2 + CVI2)1/2. Graph Pad Prism 6.0 and Matlab 7.0 were used to perform statistical analyzes.Results: Mean corpuscular volume, RDW, and reticulocyte hemoglobin content (Ret-He) had significant increases during the training period. The Ret-He were higher in C1 (32.4±1.1 pg) and C2 (32.3±1.3 pg) compared to C0 (31.9±1.2 pg) (p<0.05). It was not possible to calculate RCV for Ret-He because of heterogeneous variances. The RCV of reticulocytes (29.1%) and IRF (48.8%) were higher than Hgb (5.5%) and Hct (6.7%).Conclusion: Reticulocytes are highly variable in different athletes’ and the RCV obtained from young soccer players would contribute to monitor training adaptation and to diagnose sports anemia. The Ret-He behavior in our study suggests that this parameter can detect an early increase of iron for hemoglobin synthesis in response to training, this makes it an interesting biomarker to assess anemia and suspicion of doping by rhEPO.

Beneficial Effect of Ubiquinol on Hematological and Inflammatory Signaling during Exercise

Strenuous exercise (any activity that expends six metabolic equivalents per minute or more causing sensations of fatigue and exhaustion to occur, inducing deleterious effects, affecting negatively different cells), induces muscle damage and hematological changes associated with high production of pro-inflammatory mediators related to muscle damage and sports anemia. The objective of this study was to determine whether short-term oral ubiquinol supplementation can prevent accumulation of inflammatory mediators and hematological impairment associated to strenuous exercise. For this purpose, 100 healthy and well-trained firemen were classified in two groups: Ubiquinol (experimental group), and placebo group (control). The protocol was two identical strenuous exercise tests with rest period between tests of 24 h. Blood samples were collected before supplementation (basal value) (T1), after supplementation (T2), after first physical exercise test (T3), after 24 h of rest (T4), and after second physical exercise test (T5). Hematological parameters, pro- and anti-inflammatory cytokines and growth factors were measured. Red blood cells (RBC), hematocrit, hemoglobin, VEGF, NO, EGF, IL-1ra, and IL-10 increased in the ubiquinol group while IL-1, IL-8, and MCP-1 decreased. Ubiquinol supplementation during high intensity exercise could modulate inflammatory signaling, expression of pro-inflammatory, and increasing some anti-inflammatory cytokines. During exercise, RBC, hemoglobin, hematocrit, VEGF, and EGF increased in ubiquinol group, revealing a possible pro-angiogenic effect, improving oxygen supply and exerting a possible protective effect on other physiological alterations.

Utility of Novel Hypochromia and Microcythemia Markers in Classifying Hematological and Iron Status in Male Athletes

In athletes, no reliable indices exist for an unambiguous evaluation of hematological and iron status. Therefore, the utility of some new red blood cell (RBC) parameters was explored in 931 elite male athletes aged 13–35 years. To diagnose iron status, the values of ferritin and soluble transferrin receptor (sTfR), total iron binding capacity (TIBC), and basic blood morphology were determined in blood. The new hematological markers included among others: mean cellular hemoglobin content in reticulocytes (CHr), percentage of erythrocytes (HYPOm) and reticulocytes (HYPOr) with decreased cellular hemoglobin concentration, percentage of erythrocytes (LowCHm) and reticulocytes (LowCHr) with decreased cellular hemoglobin content, mean volume of reticulocytes (MCVr), and percentage of erythrocytes with decreased volume (MICROm). Despite adverse changes in reticulocyte hypochromia indices (CHr, LowCHr, HYPOr; p < 0.001) in the iron depletion state, the area under the receiver operating characteristic curve (AUC-ROC) values calculated for them were relatively low (0.539–0.722). In iron-deficient erythropoiesis (IDE), unfavorable changes additionally concern microcythemia indices in both reticulocytes and erythrocytes (MCVr, MCV, MICROm, and red cell volume distribution width—RDW), with especially high values of AUC-ROC (0.947–0.970) for LowCHm, LowCHr, and CHr. Dilutional sports anemia was observed in 6.1% of athletes. In this subgroup, only hemoglobin concentration (Hb), hematocrit (Hct), and RBC (all dependent on blood volume) were significantly lower than in the normal group. In conclusion, the diagnostic utility of the new hematology indices was not satisfactory for the detection of an iron depletion state in athletes. However, these new indices present high accuracy in the detection of IDE and sports anemia conditions.

Iron Homeostasis in Elite Athletes and Ultramarathon Runners

AIM: The present study was aimed at determining the effect of two different types of exercise (elite athletes playing football and ultramarathon runners on iron metabolism and, especially, the role of hepcidin in iron homeostasis. MATERIAL & METHOD: Two groups of athletes were investigated. The first group consisted of 19 male elite football athletes and the second group of 41 ultramarathon runners. In both cases, blood samples were taken pre-race (t1), immediately post-race (t2), and 24 hours post-race for football athletes or 36-48 hours post-race for ultramarathon athletes (t3). RESULTS: The iron levels in time t3 were found to have statistically significant decreases compared with the iron levels in pre-race and post-race period. Moreover, ferritin levels increased significantly in times t2 and t3. Hepcidin levels increased in time t2 in football players (from 27.45 ± 12.98 to 37.42 ± 13.74 ng/mL) and decreased in time t3. However, in ultramarathon runners, hepcidin levels significantly increased in time t2 (from 29.16 ± 10.92 to 58.81 ± 16.97 ng/mL) and remained increased in time t3 (37.69 ± 16.38 ng/mL), despite a trend for decrease. In football players, sTfR levels did not change, contrary to ultramarathon runners, where sTfR levels were found decreased in times t2 and t3. CONCLUSIONS: Iron metabolism in athletes can be impacted by the type of exercise. Ferritin is not a reliable marker for iron balance because, in the present study, it is more likely an acute-phase protein. The main regulator of iron homeostasis, hepcidin, increased, showing the body’s response to inflammation, by trapping iron in the macrophages and by altering iron absorption. Finally, a strenuous and prolonged exercise can lead to sports anemia.