What is sports anemia?

To understand sports anemia, you must first know what anemia is. In people with anemia, the body
doesn’t have enough red blood cells (RBCs). These cells transport oxygen around the body.

There are many potential causes of anemia. However, studies show that over half of all cases of anemia
are related to low iron levels in the body. Iron is essential for the production of hemoglobin, a protein in
RBCs, so low iron counts reduce RBCs and hemoglobin production.

In some cases, athletes may have “false anemia.” This occurs when the number of RBCs is normal or
even slightly increased in the athlete, but the amount of fluid in the bloodstream is significantly
increased due to changes induced by exercise. The extra fluid dilutes the blood, making the hematocrit
(a measure of the percentage of the blood that’s taken up by red blood cells) look lower than normal.
Although this is commonly called “sports anemia,” this condition is not truly anemia, as the athlete has
enough RBCs to transport normal amounts of oxygen in the body.

It’s also possible for intense physical training to lead to anemia through a few different mechanisms.

Causes of sports anemia

Athletes may also experience true anemia, which can be caused or exacerbated by intense physical
training in some people. This can occur in several different ways, including:

Hemolysis

Hemolysis is the breakdown of RBCs. When they’re broken down more quickly than they can be
replenished, anemia results. In sports, hemolysis may occur due to:

 Repeated trauma: When the feet hit the ground repeatedly during running or other sporting
activities, the impact can cause breaks in the capillaries (very small blood vessels) of the foot,
causing RBC breakdown.

 Vasoconstriction: During intense exercise, blood vessels to the muscles open widely to allow for
intense muscle activity. Blood flow to some other areas, such as the kidneys, is severely reduced
in order to prioritize blood flow to the muscles. In areas where the blood vessels are extremely
narrowed, there’s more friction against the RBCs, which can lead to their breakdown.

 Metabolic shifts: During intense exercise, there are a variety of shifts in blood chemistry. The
acid level of the blood increases and adrenaline levels rise. Body temperature also goes up, and
there’s a decrease in levels of blood cholesterol. All of these changes make RBCs more fragile
and vulnerable to damage.

Hematuria

This condition occurs when healthy red blood cells are excreted in the urine. It is mainly caused by the
following factors:

 Direct renal impact and trauma (DRIT) – DRIT may occur in sports like soccer, wrestling, and
football, where direct impacts may occur to the area of the kidneys (in the mid-back). This can
damage the kidneys, leading to bleeding.
  Prolonged impact on the bladder wall – this may occur due to repeated impact on the bladder
wall and the base of the bladder during running, jogging, or swimming, causing tears that lead to
internal bleeding.

Gastrointestinal bleeding

It’s been established that strenuous exercise can lead to digestive tract injury. This occurs because of a
severe decrease in blood flow to the digestive tract when exercising, along with the biochemical changes
induced by exercise. Over time, the lining of the digestive tract may become damaged, leading to
internal bleeding. Even if this bleeding is at a very low level and is not apparent, the loss of blood
through the intestines may eventually lead to anemia.

Inflammation

Intense exercise causes inflammation throughout the body. Inflammation interferes with the ability of
the body to use iron to make red blood cells, which can lead to anemia. It can also reduce the body’s
ability to absorb iron in the digestive tract, which can deplete iron stores and lead to iron deficiency
anemia.

Symptoms of sports anemia

In general, the symptoms of anemia are similar, no matter what the cause is. They can include:

 Loss of endurance. You may not be able to exercise for as long as you used to.

 Chronic fatigue. You may feel extremely tired, which can make strenuous exercise difficult.

 Irritability. You may find that you become more easily agitated, even by small annoyances.

 Irregular heartbeat. You may feel chest palpitations or an increased heart rate, which may be
more noticeable when engaging in exercise.

 Trouble concentrating. It may be difficult to think clearly or to concentrate on activities.

Who is at a greater risk of sports anemia?

Generally, premenopausal female athletes are at an increased risk for anemia, including sports anemia,
as women lose blood every month through menstruation. Pregnant athletes are also at a high risk
because pregnancy uses a lot of iron.

You may also be at a higher risk for developing sport-induced anemia if you've been diagnosed with
another chronic condition, such as cancer, diseases of the kidney, liver, or thyroid gland, or inflammatory
bowel diseases such as ulcerative colitis.

How is sports anemia diagnosed?

Your doctor will perform various tests to determine if you have sports anemia. The first step is to check
whether you have anemia. If so, additional testing is used to determine the cause of your anemia. The
tests done may include:

 A physical examination along with a medical and dietary history

  Tests for anemia, which may include a complete blood count (which tests the amounts of
different types of cells in your blood), hemoglobin level, or hematocrit (a test of the percentage
of your blood volume that’s taken up by red blood cells)

 Bilirubin level. Bilirubin is a breakdown product of red blood cells. Increased bilirubin levels
could indicate that red blood cells are breaking down more rapidly than normal.

 Tests of iron levels in the body. These may include serum iron (which tests the amount of iron in
your blood), ferritin (a protein which stores iron in the body), transferrin (a protein which
transports iron throughout the body), and total iron binding capacity (which tests the ability of
proteins in your blood to bind to iron and carry it around your body).

 Tests of vitamin B12 and folate levels. These two nutrients are important in making red blood
cells, and low levels can lead to anemia.

 Urine analysis to check for blood in the urine

 Endoscopic exams to check for sources of bleeding in the digestive system

Sports anemia treatment options

If you have anemia, the treatment will depend on the specific cause. Some of the treatment options may
include:

 Dietary modification – if your iron levels are low, you may be able to address this by increasing
your intake of iron-rich foods such as meat, fish, legumes, and dark green leafy vegetables. You
may also benefit from eating more foods that contain nutrients like folate and vitamin B12.

 Iron supplements – your physician will advise on the safest supplements to take for better iron
intake.

 Changing shoes – if your sport involves running or other impacts on the soles of your feet, then
wearing footwear that properly cushions and supports your feet may help to reduce the impact,
which can help to protect your red blood cells from breakdown.

 Healthy movement patterns – in some cases, you may be able to reduce the impact on your
body by changing how you perform your sport, which can also help protect your red blood cells
from breakdown.

 Moderation of your workouts – in some cases, you may need to consider scaling back the
intensity of your physical training to allow your body to recover normal levels of red blood cells.

It’s important to consider that not all cases of “sports anemia” involve true anemia. If you’re
experiencing dilution due to increased fluid in your blood, then this may not require any treatment.

Treatment: Dietary intervention, use iron-rich foods in the daily diet. Iron supplementation with ferrous
sulfate, fumarate, or citrate at a dose of 80–100 mg/d is recommended.