Feature Articles

Even Healthy Athletes Can Become Anemic

September 19, 2008

AthleteAthletes – from elite Olympians to serious recreational athletes – maintain high levels of physical fitness in order to engage in their chosen sport. The vast majority of these athletes are in excellent health, combining regular rigorous exercise with good nutrition and a healthy lifestyle. However, even the healthiest athletes may be at risk for iron deficiency and iron deficiency anemia.

Athletes are more sensitive to the effects of iron deficiency because they depend on the body’s ability to transport oxygen to the muscles. In that process, red blood cell hemoglobin and muscle cell myoblogin carry the oxygen and require an adequate amount of iron to function properly. For the athlete, a shortage of hemoglobin due to iron deficiency will cause the body to work slower and actually affect his or her performance.1 Additionally, less stored iron can negatively affect aerobic training. This can decrease energy efficiency and increase muscle fatigue and cramping.2

Athletes Most At Risk
  • Female athletes
  • Male endurance athletes
  • Runners

Common Ways Iron is Lost
  • Destruction of red blood cells
  • Through sweat
  • Through intestines
  • From taking aspirin
  • From anti-inflammatory drugs

It has been reported in several studies that athletes who are involved in heavy training may be prone to iron deficiency, which can lead to iron deficiency anemia.2,3 Those most at risk include female athletes, male endurance athletes, and runners. According to Dr. Jerry Spivak, Professor of Medicine at Johns Hopkins University, “It is well-documented that athletes are at risk of iron deficiency by a variety of mechanisms. The classic example is long distance runners, who often suffer from something called ‘foot strike hemolysis’, which is the destruction of red blood cells in the feet due to constant impact.”4 Athletes who exercise strenuously on a daily basis can also lose iron through sweat, decreased absorption of iron in their intestines, and by taking aspirin or anti-inflammatory drugs to get rid of soreness (these drugs reduce the body’s ability to absorb iron).

Iron deficiency may develop either because athletes are using more iron than they take in, there is an increased loss of iron, or by a combination of these two factors. Well-trained athletes take in and utilize iron differently than non-athletes, and this may contribute to anemia.(See table) However, the most common cause of anemia is that the athlete’s diet does not supply them with enough iron. According to Dr. Spivak, “Young women are at particular risk of iron deficiency because their average caloric intake does not match their additional iron loses due to menstruation.” Often the athlete is unaware of their dietary problem and it can continue for some time without being recognized and treated.

How Athletes Metabolize Iron
  • Iron Requirements - Training causes an increase in muscle, consequently increasing the iron requirements of athletes. This is especially noticeable early in their seasonal training.5
  • Iron Intake - Athletes involved in sports such as gymnastics, ballet, or long-distance running, in which low body weight is an asset, run the highest risk of inadequate iron intake. Vegetarian athletes are also at further risk, due to the poor absorption of iron from vegetable foods.6
  • Iron Absorption - Iron absorption is lower in athletes than non-athletes, even when both have an ample supply of iron. This decrease in iron absorption might be due to the fact that food tends to pass faster through the digestive tracts of athletes.1

How can I prevent anemia?

A sensible way for athletes to prevent becoming anemic is to consume a diet naturally rich in iron. Try to include some lean cuts of red meat, beans, lentils, dark green leafy vegetables, eggs and nuts in your diet regularly. Increase your intake of vitamin C-rich foods (including citrus fruits, berries, new potatoes, broccoli, sprouts, tomatoes, peppers and kiwis). Vitamin C helps make iron more absorbable. Don’t drink tea and coffee with meals as the tannins in them bind to iron in food, preventing it from being absorbed. Go easy on your consumption of pure bran as it is very high in phytates, which also binds to the iron.

Once iron deficiency is suspected in an athlete, they should be tested in order to determine the severity of their condition as well as which treatment options are best suited for them. The most common treatment is a combination of a well-balanced diet that is high in iron-rich foods and an iron supplement such as ferrous sulfate. If you think you may have anemia, we recommend you talk to your healthcare professional. Providing information about your eating habits or training schedule along with the Symptoms Quiz will help your doctor provide the treatment that is best for you based on what is causing the anemia. Also, read more about iron in our Anemia & Nutrition article.

Anemia can happen to everyone, even to healthy athletes – but you can usually prevent iron deficiency anemia – and that shouldn’t stop you from becoming active or competing/training in strenuous athletics. With rigorous training, a nutritious iron rich diet, and a healthy lifestyle, you too can experience the thrill of victory!


  1. Clement, D.B. and L.L. Sawchuck. Iron status and sports performance. Sports Med. 1984;1:65-74.
  2. Sinclair LM, Hinton PS. Prevalence of iron deficiency with and without anemia in recreationally active men and women. J Am Diet Assoc. 2005 Jun;105(6):975-8.
  3. Newhouse IJ, Clement DB. Iron status in athletes. An update. Sports Med. 1988 Jun;5(6):337-52.
  4. Dubnov G, Constantini NW. Prevalence of iron depletion and anemia in top-level basketball players. Int J Sport Nutr Exerc Metab. 2004 Feb;14(1):30-7.
  5. Densmore JJ. Inherited and acquired hematologic disorders in athletes. Clin Adv Hematol Oncol. 2008 Feb;6(2):111-2.
  6. Sherman AR, Kramer B. “Iron nutrition and exercise.” Nutrition In Exercise And Sports, Ed. Hickson JF, I. Wolinsky I. Boca Raton: CRC Press, 1990;291-300.