Markers of Low-Iron Status Are Associated with Female Athlete Triad Risk Factors

Abstract

Purpose: The Female Athlete Triad (Triad) is common in female athletes. The Triad is caused by low-energy availability (EA), which is often difficult to measure and has been postulated to be associated with low-iron status. Here, we explore whether markers of low-iron status may be associated with indicators of low EA including Triad risk factors. Methods: A total of 239 female National Collegiate Athletic Association Division I athletes completed preparticipation examinations that included Triad risk factors, medication/supplement use, diagnosis of anemia, and elected to complete dual-energy x-ray absorptiometry scan to measure bone mineral density. The association of markers of low iron (defined as self-report of iron supplementation and/or history of anemia) with each component of the Triad risk assessment score was assessed by stratifying low-iron status across different levels of Triad risk category. Differences across iron status groups were assessed using Fisher exact testing. Results: Every component of the Triad risk assessment score excluding delayed menarche was associated with low-iron status. The proportion of women who reported low iron was 11.5% in the low-risk EA group compared with 50% in the moderate-risk and 66.7% in the high-risk EA groups (P = 0.02); respectively. These numbers were 11.6%, 25.0%, and 66.7% (P = 0.02) for body mass index; 9.7%, 16.7%, and 25.0% (P < 0.05) for oligomenorrhea; 10.3%, 45.5%, and 50.0% (P < 0.01) for bone mineral density; and 10.4%, 20.8%, and 30.8% (P = 0.03) for history of stress reaction or fracture. Lean/endurance athletes were more likely to have low-iron status than other athletes (15.5% vs 3.4%, P = 0.02). Conclusions: Markers for low-iron status were associated with Triad risk factors. Our study suggests that female athletes with a history of anemia or iron supplementation may require further screening for low EA.

Review of the scientific rationale, development and validation of the International Olympic Committee Relative Energy Deficiency in Sport Clinical Assessment Tool: V.2 (IOC REDs CAT2)—by a subgroup of the IOC consensus on REDs

“…14 15 Nevertheless, some consistent self-reported symptoms have been correlated with LEA, leading to REDs and can potentiate the need for further assessment in step 2 and a final physician-led diagnosis in step 3. The foremost symptoms include a history of bone stress injuries (BSI), [16][17][18][19][20][21][22] menstrual cycle dysfunction, [23][24][25][26][27] low libido in males, [28][29][30] eating disorders/disordered eating (ED/DE) behaviours and various depression-related and anxiety-related symptoms. 27 31-33 It is beyond the scope of this paper to review each tool or questionnaire that has attempted to screen for symptoms, indicating a risk of LEA and/or ED/DE, leading to REDs [34][35][36][37][38][39][40][41][42][43][44][45][46][47] (for a review of these questionnaires, see Tortsveit et al 9 ).…”

Comparisons Between Serum Levels of Hepcidin and Leptin in Male College-Level Endurance Runners and Sprinters

“…Since we did not estimate accurate dietary intake (e.g., 3day weighted-food records) and energy expenditure, we did not estimate the energy valance or availability. However, compared to sprinters, a lower body fat amount, BMI, and anemia-related parameters (35,36) in endurance runners may indicate the lower energy availability. In athletes, low energy availability may cause iron deficiency anemia (1)(2)(3)8).…”

Iron deficiency in athletes: A narrative review

“…Low iron can be caused by decreased dietary iron intake either in the setting of low energy availability status in athletes 16,17 such as Relative Energy Deficiency in Sport (RED‐S) and the Female Athlete Triad 18‐20 or due to adhering to a vegan or vegetarian diet 21 . Vegan or vegetarian diets exclude the more bioavailable form of heme iron found in animal protein.…”

“…13 However, the effects of exercise on hepcidin are not as robust in iron-deficient athletes whose need for iron can override the effect. 14,15 Decreased iron intake Low iron can be caused by decreased dietary iron intake either in the setting of low energy availability status in athletes 16,17 such as Relative Energy Deficiency in Sport (RED-S) and the Female Athlete Triad [18][19][20] or due to adhering to a vegan or vegetarian diet. 21 Vegan or vegetarian diets exclude the more bioavailable form of heme iron found in animal protein.…”