Hey, everyone, good afternoon. Sorry for my strange lighting. We caught it right when the sun shined through my office window. But at any rate, I'm Robbie Bowers. I'm a sports medicine doc at Emory in Atlanta, Georgia. And today, thanks for joining us for this installment of the National Fellow Online Lecture Series. So before we get started today, I do want to plug the next lecture, which is next Wednesday, St. Patrick's Day at noon Eastern time. It will be on low back pain in the athlete. The speaker will be Dr. Ellen Casey. Today, Dr. Sarah Reiser is going to give us our talk on iron deficiency. But before we get started on that, just a couple housekeeping notes. This is to serve as an adjunct to your individual programs, educational programming. It's not to take the place of anything and also to help fellows assist in CAQ exam preparation. You will be muted during the course of the talk today. So if you have any questions, please just put them in the chat function. And then we'll hold a short Q&A session at the end, if necessary, based on the questions that are put into the chat. And then after the program, if you can please complete the evaluation, that will be sent. So with that said, today's speaker is Dr. Sarah Reiser, completed medical school at University of Florida, and then went on to PM&R residency at University of Virginia, and then her sports medicine fellowship at Stanford. She's now a colleague of mine at Emory in Atlanta as assistant professor of orthopedics and physical medicine rehabilitation. She's one of our female athlete experts and running medicine experts. And with that said, Dr. Reiser, I'll let you take it away. Thank you. Let me get my slides up here. All right. So thank you so much for having me. I'm excited to talk on iron deficiency today, which I think at face value sounds like a really boring conversation. But there are a lot of cool things that we're doing with research right now, especially in terms of optimizing our endurance athletes. So Red S, relative energy deficiency, low energy availability, whatever you want to call it, female athlete triad, all these things actually tie in pretty closely with iron deficiency as well, especially when we're talking about these endurance athletes, which I deal with a good bit in my clinics with my running medicine program. And so this is more than just a nutrient deficiency. This can actually tie to a lot of other things going on with our athletes and becoming more and more popular to screen our athletes for iron deficiencies. So without further ado, we'll go ahead and get started here. So I have no financial disclosures, but I do want to mention that I am not an endocrinologist, I'm not a hematologist, and I'm not a sports dietitian. So I'm going to be talking about iron deficiency from the perspective of a primary care sports medicine physician. So what do I do with it? When do I think we need to try to recognize it? When am I sending athletes to get further workup? And what kind of workup do I feel comfortable doing for my athletes to make sure they're optimizing their care as well as correcting any deficiencies that are going to affect their medical care? So we're going to talk about the importance of iron deficiency in the athlete. We're going to talk about what some symptoms of deficiency might be. We're going to differentiate between both non-anemia and anemia that's associated with iron deficiency. And one thing that I find particularly interesting is that we actually deal a lot more with non-anemia in terms of iron deficiency, more often so than we do with anemia. We're going to talk about an appropriate workup, talk about screening supplementation for iron deficiency in the athlete. So why is an iron important? Well, we know there's a central role in oxygen transport. But even more than that, talking kind of above and beyond hemoglobin, it's also really important in metabolism, respiratory processes, and immune function. So these are some really big components when we're talking about an athlete's health care. Iron homeostasis. So we have to talk about intake and losses when we talk about different nutrients. So our body doesn't have a great way of actually getting rid of iron besides actually bleeding. So female athletes are the only ones who really have a way of regularly getting rid of iron or larger volumes of iron anyway through their menstrual losses. But otherwise, we're absorbing through our intestinal tract from our different dietary intakes. So that's our heme sources, our animal products, and then our non-heme sources, legumes, greens, and rich cereals. And then we have some minimal losses through the GI system on a daily basis. And then again, menstruation for females. Low iron can result in a number of different symptoms. And a lot of times they're really vague. They're things that athletes can't quite put a finger on. Something's not right. But I know there's something going on and I can't pinpoint it. So they may come in with low mood, irritability, depression. They may also come in with just a vague complaint of fatigue. So checking iron is a common lab marker that we're gonna look at if someone's coming in with fatigue and we're doing kind of a general workup. They may have dizziness, increased resting heart rate, and unexplained drop in performance. So poor performance is probably one of the most common reasons I have someone come in. I have had fatigue be a regular comment, but oftentimes it's, hey, I'm not running the way I usually do and I don't have a reason for it. I should be progressing like I usually do. I'm eating the same things, what's going on? So iron deficiency, as you can imagine, is more common in our females. In terms of our female athletes, 15 to 35% is a pretty high number to think about iron deficiency. Our male athletes still 5 to 11%, which is still a significant number of our runners and endurance athletes, especially, that we're treating that have iron deficiency. And again, this is not necessarily with an anemia. So this may just be a low iron level that we're looking at. And then when we're talking about homeostasis in athletes specifically, we wanna think about increased iron demand. They may have increased hemoglobin mass, especially if they're going to altitude, for example. And in the context of low energy availability, we also wanna think about the consequences that if an athlete is not getting sufficient caloric intake, you can imagine that the percentage of iron they're getting in their diet also is likely not sufficient. And interestingly, there are very few people who are really getting a sufficient amount of iron in their diets from our athlete point of view. So it's pretty tough. You know, there was one estimate of about, female athletes needing about 70% higher of an iron intake than the average female who is sedentary. And that's pretty significant when we already have, can have trouble getting enough iron in our diets to begin with. And then one thing I think is really interesting is thinking about hepcidin and its impact on our absorption of iron. So hepcidin is actually going to reduce absorption of iron and you have release of hepcidin with intense exercise. Most of our athletes, especially those who are in season are doing intense exercise. And so if they have these hepcidin bursts and then they're eating within a few hours of that timeframe, they're actually gonna have a lower percentage absorption rate of their iron after that intense exercise episode. And so it's important to consider, you know, when we're timing our iron intake, if we have an athlete that's having trouble maintaining their iron levels. And then I think it's so interesting when we talk about this, you know, intertwining of red S. So this low energy availability state. So like I was talking about before, if your overall caloric intake is not being met, then you are likely also not meeting your needs in terms of all your micro and macro nutrients. So iron is likely suffering as a result of that. You know, if you have low iron intake, poor absorption or suppressed sex hormones, those are all gonna affect our iron absorption. And that's going to be kind of sometimes chicken or the egg. So is it that your iron deficiency kind of led you into this low energy availability state or vice versa? And I tend to think that everything's really intertwined. So interestingly, low testosterone and low estrogen can both affect hepcidin release. And so if you've got higher hepcidin release with these lower hormone levels, you actually have decreased ferritin. So if we, again, relate this back to our red S and low energy availability state, these athletes with lower hormone levels are actually potentially gonna be prone to having lower ferritin as a result of the hormones too. Or potentially dissociation. One study that I thought was really interesting in kind of trying to prove this point is that some athletes were provided hormonal contraceptives if their ferritin was quite low. So that's less than 10, which is having almost no iron stores whatsoever. And their ferritin levels actually increased a relatively nominal amount, but it was significant. And so again, putting in, giving you more impetus into the importance of our sex hormones, just another reason for our athletes to kind of understand the importance of sufficient energy intake. And I thought this was pretty eyeopening. So many negative health outcomes associated with red S can be exacerbated by iron deficiency. For example, low iron stores are known to perturb thyroid function, decrease appetite and impair metabolic efficiency. Alterations of which can lead to reduced energy intake, increased energy expenditure, and potentially contribute to low energy availability in our athletes. So again, chicken or the egg. So which thing is occurring first? So I think the checking iron can be a great way to evaluate if someone already has nutritional deficiency. Often one nutritional deficiency comes along with multiple others. So that can be your clue into thinking either something else going on that we need to look into. So a few little tidbits on kind of iron deficiency and performance. So there are a number of studies. We've actually got a good number of conflicting studies, which if you look at the methodology, that can probably help explain some of the conflict. We have some things suggesting that performance is not affected and some things suggesting that it is affected. So if we look at a few of these studies, female collegiate rowers with iron deficiency, non-anemia, maintain significantly lower weekly mileage as compared to rowers with normal iron levels. So suggesting that iron deficiency, even without anemia, was affecting an athlete's ability to maintain higher volumes of training. Multiple studies have suggested decreased aerobic capacity in the setting of iron deficiency, non-anemia. And this was proven by showing that this would improve with supplementation of iron products. Gradually, we've also got some studies that show there's no effect on aerobic capacity as well. There's been some studies showing improved mood with supplementation of ferritin levels less than 50 in non-anemic women. And as we look at the numbers that we're gonna consider in terms of, well, what is the low ferritin? We still have a lot of conflict about what number we're gonna look at and say, oh, you're deficient, we need to supplement. Or maybe you're insufficient and we're still gonna supplement you to a higher level. So this was interesting that less than 50, which is generally considered a normal ferritin, that these folks actually still improved with their mood. Female military recruits had improvement in their running performance with iron deficiency anemia, but those with non-anemia only showed mood improvements. So potentially we could be talking about, hey, performance is really affected from a physiological standpoint with the anemia, but then women with the non-anemia, now they're just showing things like changes in mood, but that can be a big deal. So when you're talking about an athlete with trouble with fatigue or mood changes, that can really impact someone's performance. And I think that's almost as important or equally important as someone's physiological performance. In knee extensor strength increased with iron supplementation, iron deficiency, non-anemia, VO2 max, and runtime to exhaustion increased with iron infusion. So lots of different things have been tested in terms of finding out, well, how to strength, endurance, VO2 max, runtime, how do all these things change with iron supplementation. This last study I thought was interesting, the VO2 max and runtime to exhaustion, because what they were doing was an iron infusion with a ferritin of less than 65. So 65 is certainly considered from a lab standpoint, a ferritin of 65 would be considered normal. And they were still showing the supplementation as long as it was under 65, they would still get some change. Iron infusion is gonna be relatively, potentially short-lived in terms of the improvement in the ferritin level. And so that's one thing to kind of consider with that study, but they showed higher ferritin levels and improvement pretty quickly. So lots of interesting research that's being done right now. And there's lots more out there. So when we talk about ferritin, as I've already alluded to, this is our cellular storage of iron. And this is really our biomarker of total iron stores. So it's most commonly used, it's an efficient and expensive way to give you kind of a face value of, what do the iron stores look like in the body? Oftentimes, this is even looked at potentially in isolation from other iron biomarkers as well. The one thing we wanna be particularly cautious about with this is that ferritin is also an acute phase reactant. So if you have someone who has any kind of acute or chronic illness, or they've recently done intensive exercise, which is certainly pertinent to our athletes, that this number can actually be elevated and could potentially hide an iron deficiency that we're not otherwise seeing. So we wanna make sure that athletes are healthy when we're testing their ferritin. And then again, this lack of standardization of low ferritin is pretty significant. So if we talk about ferritin levels, I've read articles from Switzerland and from the UK, from the US, there are all kinds of different opinions about what is considered a low ferritin and when are we gonna supplement? So this particular article, these numbers seem to be relatively consistent across the board, that a ferritin level of less than 15, sometimes people call it 12, sometimes 10, that you have empty iron stores with this. So kind of the gold standard is looking at bone marrow stores, do those still exist? And obviously that's a tougher thing to do than to just check a serum ferritin. But the idea is that this tends to correlate with empty iron stores. So oftentimes this is gonna warrant a state extended workup. So is there blood loss that's happening somewhere? Is there something else really significant that's going on? So if I get a ferritin under 15, I'm typically doing a little bit more workup or potentially even getting them in with hematology for an additional workup, especially when I get those numbers like six. For 15 to 30, we talk about having low iron stores. So now our iron stores are not complete. They're starting to get depleted, but we're not completely empty at this point. Above 30, we consider iron stores to be replete. But then the question is, can we benefit from higher levels? You know, is 30 sufficient? You might also consider, you know, if you're going into a season and you're replete, as you start increasing your volume and your intensity of exercise, are we potentially gonna drop down? So do we wanna do something like preloading per se? Is that gonna be helpful? And those are still some questions that are out for debate. For altitude training, kind of the general thought is getting up to a goal of 50 micrograms per liter in terms of your ferritin levels. So oftentimes we're gonna supplement beforehand to get them up to that number with the idea that that ferritin level is gonna drop at altitude and that you need all this iron to actually reap the benefits of your altitude training. Otherwise, you know, you're gonna deal with fatigue and you're not actually gonna benefit from that training as much as you optimally could. So again, when we talk about iron balance, we wanna talk about intake and output. So in terms of the intake, a few other things that we need to think about are not only our diet, but how diet may be affected by dietary restrictions. So our athletes who aren't eating meat products, they're not getting the heme iron that is much more readily absorbed. They may have a harder time meeting their iron needs. Disordered eating is certainly gonna play a role or simply low energy availability. Timing of intake with other foods. So things like coffees and teas, the polyphenols are gonna act as a, are gonna prevent absorption of iron. And in supplements like calcium are also gonna prevent absorption of iron. Oftentimes these athletes are also taking calcium supplements. So you wanna make sure that you're timing things appropriately so that you're getting proper absorption of all the supplements that you're taking, as well as the best dietary intake absorption that you can. One thing to think about from the output standpoint, and I alluded to this on the last slide with the really low ferritin levels, is there something pathologic that needs to be worked up? Do we have some kind of GI pathologies there bleed somewhere? And if that's the case, that's where we're getting the CBC and further workup to identify, do we have an anemia? Is it normocytic? Is it microcytic? So starting to identify, is there something pathologic needs to be addressed? And that's a really important thing that you don't wanna forget. You don't wanna just screen a ferritin and say, forget it. I'm just looking at the number. You've gotta put it in the context of the athlete as well. So there are stages of iron deficiency that have been characterized. So generally they're put into about three categories. So your first category is iron deficiency without anemia. And that can be split up into just initially having a low iron content. So you'll have a low ferritin. And then as you get into the second stage, you start getting some changes in some of the iron markers. So you'll have a low iron, low transferrin saturation, increased TIBC. But you're not quite to the anemia stage yet. So still normocytic, normal hemoglobin. As you progress on to the later stages of iron deficiency anemia, you're gonna have more severe ferritin, severely decreased ferritin. And that's where you start noticing microcytic anemia. So looking at the MCV can give you information. The hemoglobin should be below normal as well. And this is gonna be actually a lot fewer of our athletes that are in this category. So oftentimes the majority of the athletes I'm treating are really in that non-anemia stage. And the idea is, for one thing, we wanna optimize performance and health, but we also wanna prevent them from getting to that severe stage where they really start affecting their performance levels. So who do we check? And there's a number of ways to look at this. It's becoming a lot more common to start doing screening. A lot of our runners, endurance athletes are getting screens on a regular basis, such as our elite athletes who are getting labs a couple of times a year just to check a ferritin and make sure everything looks good. And we're essentially optimizing. So we're actually treating a little bit higher than, in general, we're treating a little bit higher than what would be considered an adequate ferritin level. You may even consider looking at athletes, if you have concerns, if you have concerns with disordered eating, low energy availability, this is often part of the workup for that as well. You wanna consider if they have low BMI, are we worried about it? Adolescents are gonna be more predisposed to it, especially as they're going through menarche and having a change in their bodies and iron losses. And then vegetarians, of course, oftentimes we're gonna have a lower threshold to screen them as well, because it's a lot harder to get that readily available absorption from iron with them. Athletes who have a history of iron deficiency, we're often monitoring on a regular basis as well. And then certainly if someone's symptomatic, we're checking. So kind of getting to that poor, hey, I have poor performance. I have no idea what's going on. Something's just not right. Or coming in with significant fatigue, they're sleeping a lot. They can't recover like they used to. Oftentimes it's gonna be a part of a workup when we're looking at burnout and other issues with energy levels. And then again, our elite athletes that are heading to altitude for training, we're checking as well to make sure we're optimizing their ferritin levels before sending them off. So how do we check levels? Well, like I alluded to, sometimes just checking a ferritin, getting a ferritin and vitamin D is often a regular screen for some folks, but really you do need that CBC to be able to characterize if that ferritin is low. The other thing you wanna consider too is your ferritin could look normal and you could have anemia and the ferritin could be high simply because you have an inflammatory process that's going on. You could be sick. So getting a CRP ESR to be able to evaluate is there an inflammatory or infectious process going on can also help kind of put that ferritin into context. So ultimately our initial screen with that CBC, ferritin and CRP, I think is the most effective and gives you the good amount of information without being a massive workup. Now, if these numbers are abnormal, oftentimes we're progressing on to getting a little bit more workup. So usually towards that low energy availability workup, again, depending on the context. But other things we might consider getting is an iron panel, retic count, and then even checking things like for celiac disease, which oftentimes iron levels can be low for that as well. And then a stool guaiac, which might look for a potential bleeding source if we're worried from that standpoint. And again, looking for neurocytic anemia is more of what we're looking at if we're looking for someone who's having a lot of bleeding. Oh, and the one other thing I wanted to mention here too, is if we're starting to get down that celiac disease path, stool guaiac path, we're often sending these folks to an additional specialist, whether that's hematology, endocrinology, GI, depending on what's going on. So oftentimes we're bringing in other specialists to make sure that we're not missing something additional. So we don't wanna just fix iron levels. That's not always gonna be the answer. We need to remember how this fits into the overall picture of our athletes in general healthcare. So what number do we treat? And again, this is out for debate. You know, we have one article that went through, or meta-analysis went through a bunch of different studies and showed that in general, ferritin less than 20 deserve to be addressed and supplemented. Now, this was mainly because the studies that they were looking at, their cutoff was 20. And so they were checking all these athletes below 20 and above 20. Now we're starting to kind of understand a little bit more that we think ferritin less than 30 might be worth supplementing at that point. So our levels are getting a little bit higher, although I will tell you that our lab, the cutoff is 20. So it's variable. And I'll have athletes who come in from primary care sources, and they've been told, oh, ferritin looks fine, it's 21. And I would supplement that for an endurance athlete. And then we also have this ferritin of 50. And I would say this is much more of an anecdotal ferritin. So there are a couple of studies that have looked at, you know, I alluded to earlier, we talked about a ferritin of 65. That was one of the cutoffs they were looking at in terms of symptoms of iron deficiency. So below 65 in their study was actually worth supplementing. There've been some studies where below 50 was worth supplementing. And 50 tends to be kind of our number that we're looking for in terms of maximizing iron levels before we're going to altitude. So 50 tends to be the number that I'm looking at. But again, I think in a lot of ways, this is a little bit more anecdotal. The 20 to 30 mark has been looked at a little bit more. And then again, the other thing to think about too is a ferritin under 15 is generally considered empty stores and that's very significant. And so that's kind of a different class on itself that we need to consider. So over 15 years of age, generally we're treating less than 30. Two to six weeks before training altitude, you may want to supplement to a goal of 50 to get the most out of your training altitude. And then, you know, there's this question of, should we consider loading in the off season? You know, vitamin D levels we can load in some ways and same thing with iron, maybe harder for athletes to get in the content that they need in their diets during the season, depending on how much they're training. I've had a lot of challenges with division one collegiate runners and other endurance athletes that have trouble getting in the nutrition they need because they're practicing twice a day and maybe they have a GI upset if they eat too close to meals or they have trouble with their appetite as a result. So it tends to be a little bit easier when they're in the off season to be able to get those nutrients they need. Potentially not the best way, but certainly something to kind of consider. So how much iron do people need? So about 18 milligrams per day for women. These are adults age 19 to 50 and about eight milligrams per day for men. So pretty significant difference between the two. During menses, athletes are typically going to lose about one milligram per day, which in my head, I think, oh, it's not that much. But, you know, if you're running in an iron deficiency already or insufficiency, and then you're having these losses on a monthly basis, they can end up adding up. And then there's also this thought that this may not be a sufficient amount for athletes. So if we have, you know, if athletes have a higher hemoglobin mass and they have more iron demands, potentially 18 milligrams and eight milligrams a day is not going to be enough. And we need to think about having higher amounts. Again, from more of a dietary standpoint is going to be the most important part. We're going to talk about that next. So how do we get iron into our diets? Well, there's a number of different sources. We talk about heme and non-heme sources. So heme sources are going to be our animal products, which are going to be more readily available. But interestingly, if you look at these numbers, they may not, you know, these are all based on a single serving size. They may not be a particularly large amount, even in our meat products. Even things like milk and cheese, eggs aren't really high in iron. Interestingly, I think it's a little ironic our fortified cereals can have a lot of iron in them. I think I looked at my Cheerios and I think they had like less than half of this amount, not 18 milligrams or a hundred percent. I think it was 20% of your daily content. But the ironic part is we often pour milk over our cereal. So we have these fortified products with iron and then we're drinking it, we're consuming it with calcium products, which actually inhibit absorption. Now in the average person who's getting plenty of iron, that's really not something of concern. But in your athlete, who's having trouble getting sufficient iron intake and we're trying to improve that intake and improve absorption, we may not be wanting to consume all these calcium laden products first thing in the morning, maybe potentially after they've had their iron supplement, they're having their fortified cereal. We don't wanna have that additional calcium that's gonna prevent absorption or optimal absorption. So a lot of things to think about here. Interesting dark chocolate is a pretty high, which I thought was refreshing. And then beans and tofu, you know, these things have a lot of iron in them when you think about serving size. However, it's not as readily absorbed. So even though, so beef and chicken, tuna, eggs, only one to two milligrams for a serving, but it's much better absorbed. So lots of different methods that we can think about in terms of how are we gonna optimize this. Now, when we talk about treating iron deficiency, we really wanna think about what are our goals and what is the urgency? So again, this is from an athlete perspective. So we have an athlete who has, you know, a major national championship in two weeks and their iron level's low and they're suffering as a result of it. We may be considering, hey, we need to go the IV route and we need to get this fixed right away. We're gonna work on these other things right now as we can, but, you know, oral dietary intake is not gonna increase, you know, a ferritin of five or six in time for someone who's symptomatic and is gonna be participating in a national competition. So oftentimes the urgency ends up being a big component of our athlete treatment. One thing we have to think about is anti-doping policies. So you've gotta make sure that if you are treating these athletes that you understand the rules and you're doing things appropriately and potentially getting TUEs to make sure your athletes are not getting disqualified because you're optimizing their iron intake. So with all of our athletes, I'm going through definitely nutrition counseling. Oftentimes we're supplementing. So if you've got a number, especially below 15, but even below 20 and 30, I'm often doing some supplementation as well. And this is gonna be oral. And once we get to optimized levels, my hope is that by that time, they've gone through the nutrition counseling and now their iron that they're taking in by food has improved significantly as well. And so we can hopefully maintain. The IV piece is more for those really symptomatic patients or athletes, as well as kind of that urgent athlete who needs to fix their ferritin levels pretty quickly. So when we talk about nutritional counseling, it always helps to have a good sports dietician on hand. I send to them, I don't have anyone who I have come in with a low ferritin that's not gonna get sent to a sports dietician. They can assess their daily dietary intake of iron. And just kind of like when we look at runners biomechanics and I show the mechanics to the athlete, same thing here. You wanna show them what they're eating and kind of open their eyes and understand, where am I missing things? I thought I was eating a healthy diet. So it can be easy to miss some of these issues here without kind of taking the time to look through it. And the dietician can help them with that. We're unlikely to correct deficiencies by diet alone. So again, under that level of 20 to 30, we're gonna do an oral supplement, not forever. I'm just like, I don't like to do my arch supports forever. I don't wanna do my iron intake, iron supplementation forever either. So the idea is to get them corrected and then they maintain that correction with their improved nutrition. Benefit of nutrition also is that we're not gonna overload them with iron. So interestingly, iron is actually one of the most common methods of overdose in children under six. So you can overdose on these medications. Now, children who are six years old have much lower needs of iron. And so it's a lot easier for that. But once we get to older adults, if we're taking a large amount of iron, I had someone who was coming in taking I think 300 milligrams a day or something of that nature. I was like, we got to back off on this. This is too much. You're not gonna get too much from your dietary intake. Your intestines are gonna get rid of it and absorb it. So you don't have the same benefit from your supplementation. Timing of meals, composition of meals, like I was alluding to with the cereal and milk idea, that's gonna be important as well as if you're supplementing with an oral iron tablet. And then I found another kind of interesting tidbit. So in vitamin D deficient individuals, vitamin D supplementation reduced hepcidin levels, thus increasing iron absorption. So again, one nutritional deficiency often goes along with another. So you wanna be checking kind of the whole picture when you find athletes who have any kind of deficiency. What does their vitamin D look like? In terms of diet, iron-rich foods, we've talked about this a few times already. Meat products are gonna be your better absorption option. And then your non-meat products are gonna be where you actually get more of your general content of iron. So you're gonna consume more of it that way. However, you're gonna absorb less of it. In terms of our oral supplementation, there's a couple of different methods, ferrous sulfate, ferrous gluconate. You may see it in pill or liquid form. And you've got a 10 to 35% GI absorption rate. So pretty good. And side effects are dose dependent. So usually the main things people complain about is gonna be constipation. And the higher your dosing, the more likely you're gonna have trouble with constipation. So if we can minimize those numbers, the less we're gonna affect our athletes. Supplementation is just not standardized. Oftentimes it ends up being 65 milligrams elemental iron is how much you're taking at least because that's where our pills are typically. Those are the ones that are most commonly formulated. So especially if you have athletes who come in and they're already supplementing, that's usually what they're taking is that 65 milligram tablet of elemental iron. But the root dose and frequency, again, all those things are still kind of up for debate. There is more information coming out suggesting that we do every other day supplementation. And the reason for that is, one of the reasons is hepcidin release. So if you give a large dose of iron, your body produces hepcidin and says, hey, I don't need to absorb anymore, I've got plenty. And that potentially can stick around for a couple of days. So if you supplement the next day, your body goes, oh no, it's too much and gives you that hepcidin again and you're still not absorbing. So having an everyday other day supplementation can be helpful and actually have better absorption than if you did a daily supplementation. Fasting is the way we typically recommend that folks take their iron supplements, that it's better absorbed that way. However, it can also cause GI upset. So I usually work with my athletes, if they have any issues with that, then we work on other options in terms of preventing that GI upset. Taking it in the morning means you're taking it before workouts, before you have the opportunity to get those hepcidin burst. And then I usually recommend taking with vitamin C. So an orange juice supplement give you that acidic stomach environment as well as the vitamin C to help with the absorption. Again, avoiding things that are gonna block absorption, avoiding them with those meals. So coffee, tea, calcium rich foods. There's a few others too, but these are gonna be the most common ones. And then consuming a vitamin D, vitamin C, I'm sorry, fermented foods and organic acids are gonna help with the absorption. And again, thinking about, are you exactly taking any other medications that can interfere? PPIs are a big one. So you decrease your gastric acid content and you're also gonna decrease the ability for your iron absorption to occur. So keeping things in mind in that direction as well. For IV absorption, we consider it, in quotes, 100% absorption, right? So you're not having to go through the initial absorption through the gut and GI system. So this is what we use if we've got an athlete that's very symptomatic or they've got competition that's coming up quickly. Or this could be when oral therapy fails. And if oral therapy is failing, you wanna find out why is this happening. Again, you wanna be collaborating with another specialist as well. Sometimes oral therapy is not tolerated. So GI upset, constipation, those sorts of things may mean that we're getting to the IV as well. And again, don't forget to look at your anti-doping regulations. Important that you recheck levels. So if you're doing an IV infusion, you're rechecking levels pretty quickly. For folks who are doing even dietary, but also if they're doing any kind of iron supplementation, for one thing, you wanna make sure they're not overdosing on it, but you also wanna see, hey, when are we getting to levels where we can try to taper off of the supplement and really just stick with our dietary iron intake? So this may look like looking six to eight weeks if we're doing a pretty significant supplementation that we're rechecking ferritin, or we're looking every two to three months that we're doing a maintenance dose. And in our elite athletes, this is a common way that we're looking at this. So a couple of times a year, or maybe a little bit more frequently if we've had trouble with this, or an athlete that we're dealing with low energy availability and we're managing this pretty tightly. So again, can't forget about iron overdose. Vitamin D, I think one of the joys of vitamin D is in general, we're not gonna overdose unless you eat a huge amount of vitamin D and take a whole bottle. We're really not gonna get too much vitamin D. It takes a pretty large amount to actually have issues with that. So I think we have a pretty safe therapeutic window there. In terms of iron overdose, there's really no route for elimination in cases of overload besides bleeding. So you think about hemochromatosis and actually pulling blood off to get rid of the iron and then menstrual losses in women, but we otherwise don't have a way to regulate that. So you wanna make sure your athletes aren't overdosing. You have an increase in oxidative stress, so free radicals as a result of the iron. So there are some studies, I'm not gonna get into the details of it or specifics, but there are some studies suggesting that, hey, if the intestines exposed to a lot of iron, do we have the possibility that we're more likely to have tumor growth? So iron is not totally benign. We wanna make sure we're not giving them too much either. And then large loads of irons have been associated with decreased zinc absorption. So if you're overloading an iron, are we having issues elsewhere? Are we not getting the other nutrients that we need? And then chronic overload can lead to secondary hemochromatosis. That's getting me a little bit of a stretch. Unlikely that we're gonna get there unless you've got an extreme athlete that's just going overboard with it. So long-term supplementation is really not recommended, especially with normal or high ferritin levels. So we wanna really, we wanna give them the minimum that we have to. So we supplement them, get them where they need to be, and we hope that we can get that, the dietary changes to hold on and maintain the athlete without having to constantly give them supplementation. Plus it's annoying. You gotta take it fasting, empty stomach, first thing in the morning without food, and wait a couple hours before you eat. It's a whole deal ordeal that you've gotta manage every single day or every other day. So intermittent supplementation is really how we wanna do this, especially for someone who's chronically low. So we're not doing this constantly, but certainly the three days a week or every other day supplementation, I think is also a great way to do this so that you're not, so you're minimizing the impact. So to summarize here, so iron deficiency is more common in our athletic population, but it affects both men and women. So this is not just an issue that we deal with in our female athletes, our men do as well. And especially in our endurance athletes, our runners, our aesthetic athletes with lower body mass, these are athletes we wanna have a lower threshold to be checking iron levels. And iron deficiency as well as the anemia may affect performance. We've got more data suggesting that the iron deficiency anemia affects performance, but we do still have some data suggesting that even with an iron deficiency with non-anemia, we're still getting some deficits in performance as well. Iron stores may be affected by dietary intake, dietary intake patterns, hormones, GI absorption and losses, menses, high-intensity exercise and altitude. So it's not as straightforward as we might think. There are a lot of things that we need to really take into context in terms of our holistic care of the athlete to figure out how to best help them. An early detection of iron deficiency and appropriate treatment. So thinking about counseling, supplementation as appropriate can really help prevent worsening of deficiency. And you really wanna prevent that subsequent poor performance. An athlete who's coming in because they're underperforming and they don't know why. All right. So thank you so much for your attention. I appreciate it. Thanks again for having me and I'll take any questions if you've got them. Thanks, Sarah. Great job. Isn't it interesting that you and I are in the same room and people don't even know it? It's strange. No, it's very weird. Okay. So there were one or two questions in the chat. Okay. So the first one is from Calvin and... Sorry, my chat just went away. Give me one second. So he's asking if... Oh my gosh. Sorry, I'm challenged. If women only lose one milligram per day during menses, why the huge gender gap in iron needs? Yeah. That's a great question. Thanks, Calvin. So what I attribute it to, and again, this is a little bit anecdotal from my perspective. I'm not quoting studies, but my assumption would be that low energy availability tends to be a little more common in our female athletes as well. And so if you have a overall lower caloric intake, which often our female athletes generally have somewhat lower needs, caloric needs than our counterparts, male counterparts, it's gonna be a lot harder to get those iron needs. And that kind of percentage. So if you're already not meeting your needs, if you are consuming the correct number of calories, and then you're trying to drop that and restrict it, then you're getting even less iron intake as well. So that's kind of how I attribute it in my mind. But again, kind of anecdotal and a little bit of guessing there, but that would be my assumption too. Okay, great. So that was the only question in the chat. If anyone else wants to throw in in there right now, if you have any last second questions. Otherwise, I will say thanks Dr. Reiser, and we really appreciate it. Wanna plug the talk for next week again, Dr. Ellen Casey will be presenting on low back pain and the athlete that will be on March 17th. So Wednesday next week at 12 noon Eastern time, I'll be moderating that one as well. So please feel free to come on back for that lecture. And then as far as this one goes, it will be uploaded here either later tonight or tomorrow to the AMS SM YouTube page for free viewing there as well. So thanks a lot, everyone for coming today. Join us next week and Sarah, we appreciate it. Thank you.

3rd Edition, CASE 24

3rd Edition

Hematology

iron deficiency

athletes

sports medicine

performance

dietary interventions

iron supplements

Emory University

Dr. Sarah Reiser