Abstract
While the crucial role of haemoglobin in aerobic exercise has been well accepted, there is still a great deal of controversy about the optimal haematological parameters in the athletic population. The initial part of this review will examine the question of anaemia in athletes. The most common finding in athletes is a dilutional pseudoanaemia that is caused by a plasma volume expansion, rather than an actual blood loss. It is not a pathological state and normalizes with training cessation in 3 to 5 days. This entity should be distinguished from conditions associated with lowered blood counts, such as intravascular haemolysis or iron deficiency anaemia. The evaluation of true anaemia states in the athlete must take into account not only blood losses secondary to exercise, such as foot strike haemolysis or iron losses through sweat, but non-athletic causes as well. Depending on the age and sex of the athlete, consideration must be given to evaluation of the gastrointestinal or genitourinary systems for blood loss. Finally, a comprehensive nutritional history must be taken, as athletes, especially women, are frequently not consuming adequate dietary iron.
The second section of the paper will deal with the very contentious issue of sickle cell trait. While there have been studies demonstrating an increased risk of sudden death in people with sickle cell trait, it is still quite rare and should not be used as a restriction to activity. Further, studies have demonstrated that patients with sickle cell trait have an exercise capacity that is probably normal or near normal. However, in the cases of sudden death, it has been secondary to rhabdomyolysis occurring among sickle cell trait athletes performing at intense exertion under hot conditions, soon after arriving at altitude. The recommendations are that athletes with sickle cell trait adhere to compliance with the general guidelines for fluid replacement and acclimatisation to hot conditions and altitude.
The final section of the paper examines the issue of haematological manipulation for the purposes of ergogenic improvement. Although experiments with blood doping revealed improvements in running time to exhaustion and maximal oxygen uptake, the introduction of recombinant erythropoietin has rendered blood doping little more than a historical footnote. However, the improvements in performance are not without risk, and the use of exogenous erythropoietin has the potential for increased viscosity of the blood and thrombosis with potentially fatal results. Until a definitive test is developed for detection of exogenous erythropoietin, it will continue to be a part of elite athletics.
Similar content being viewed by others
References
Eichner ER. The anemias of athletes. Physician Sports Med 1986; 14 (9): 122–30
Hallberg L, Magnusson B. The etiology of ‘sports anemia’. Acta Med Scand 1984; 216: 145–8
Balaban EP. Sports anemia. Clin SportsMed 1992; 11 (2): 313–25
Weight LM. ‘Sports anemia’: does it exist? Sports Med 1993; 16 (1): 1–4
Wells CL, Stern JR, Hecht LH. Hematological changes following a marathon race in male and female runners. Eur J Appl Physiol 1982; 48: 41–9
Dill DB, Braithwaite K, Adams WC, et al. Blood volume of middle-distance runners: effect of 2,300-m altitude and comparison with non-athletes. Med Sci Sports 1974; 6: 1–7
Weight LM, Darge BL, Jacobs P. Athletes’ pseudoanemia. Eur J Appl Physiol 1991; 62: 358–62
de Wijn JF, de Jongste JL, Mosterd W, et al. Haemoglobin, packed cell volume, serum iron and iron binding capacity of selected athletes during training. J Sports Med 1971; 11: 42–51
Brotherhood J, Brozovic B, Pugh LGC. Haematological status of middle- and long-distance runners. Clin Sci 1975; 48: 139–45
Telford RD, Cunningham RB. Sex, sport, and body-size dependency of hematology in highly trained athletes. Med Sci Sports Exerc 1991; 23: 788–94
Clement DB, Asmundson RC, Medhurst CW. Hemoglobin values: comparative survey of the 1976 Canadian Olympic team. Can Med Assoc J 1977; 117: 614–6
Weight LM, Klein M, Noakes TD, et al. ‘Sports anemia’: a real or apparent phenomenon in endurance-trained athletes? Int J Sports Med 1992; 13: 344–7
Risser WL, Lee EJ, Poindexter HBW, et al. Iron deficiency in female athletes: its prevalence and impact on performance. Med Sci Sports Exerc 1988; 20: 116–21
Balaban EP, Cox JV, Snell P, et al. The frequency of anemia and iron deficiency in the runner. Med Sci Sports Exerc 1989; 21: 643–8
Stewart GA, Steel JE, Toyne AH, et al. Observations on the haematology and the iron and protein intake of Australian Olympic athletes. Med J Aust 1972; 2: 1339–43
Pate R. Sports anemia: a review of the current research literature. Physician Sports Med 1983; 11: 115
Dotan R, Rotstein A, Dlin R, et al. Relationships of marathon running to physiological, anthropometric and training indices. Eur J Appl Physiol 1983; 51: 281–93
Eichner ER. Blood doping: results and consequences from the laboratory and the field. Physician Sports Med 1987; 15 (1): 121–9
Fleischer R. Ueber eine neue form von haemoglobinurie beim menschen. Berl Klin Wochenschr 1881; 18: 691
O’Toole ML, Hiller WDB, Roalstad MS, et al. Hemolysis during triathlon races: its relation to race distance. Med Sci Sports Exerc 1988; 20: 272–5
Dufaux B, Hoederath A, Streitberger I, et al. Serum ferritin, transferrin, haptoglobin, and iron in middle- and long-distance runners, elite rowers, and professional racing cyclists. Int J Sports Med 1981; 2: 43–6
Selby GB, Eichner ER. Endurance swimming, intravascular hemolysis, anemia, and iron depletion. Am J Med 1986; 81: 791–4
Schwellnus MP, Penfold GK, Cilliers JF, et al. Intravascular hemolysis in aerobic dancing: the role of floor surface and type of routine. Physician Sports Med 1989; 17 (8): 55–67
Wolf PL, Lott JA, Nitti GJ, et al. Changes in serum enzymes, lactate, and haptoglobin following acute physical stress in international-class athletes. Clin Biochem 1987; 20: 73–7
Falsetti HL, Burke ER, Feld RD, et al. Hematological variations after endurance running with hard- and soft-soled running shoes. Physician Sports Med 1983; 11 (8): 118–24
Davidson RJL. Exertional haemoglobinuria: a report on three cases with studies on the haemolytic mechanism. J Clin Pathol 1964; 17: 536–40
Smith JA. Exercise, training and red blood cell turnover. Sports Med 1995; 19: 9–31
Szygula Z. Erythrocytic system under the influence of physical exercise and training. Sports Med 1990; 10: 181–97
Selby GB, Frame DC, Eichner LK, et al. Athlete’s echinocytes: new cause of exertional hemolysis [abstract]? Blood 1987; 70: 56A
Sanborn CF, Jankowski CM. Physiologic considerations for women in sport. Clin Sports Med 1994; 13: 315–27
Clement DB, Sawchuk LL. Iron status and sports performance. Sports Med 1984; 1: 65–74
Harris SS. Helping active women avoid anemia. Physician Sports Med 1995; 23 (5): 35–47
Selby GB. When does an athlete need iron? Physician Sports Med 1991; 19 (4): 96–102
Addy DP. Happiness is: iron. BMJ 1986; 292: 969–70
Cook JD, Finch CA, Smith NJ. Evaluation of the iron status of a population. Blood 1976; 48: 449–55
Cook JD, Skikne BS, Lynch SR, et al. Estimates of iron sufficiency in the US population. Blood 1986; 68: 726–31
Clement DB, Asmundson RC. Nutritional intake and hematological parameters in endurance runners. Physician Sports Med 1982; 10 (3): 37–43
Rowland TW, Black SA, Kelleher JF. Iron deficiency in adolescent endurance athletes. J Adolesc Health Care 1987; 8: 322–6
Nickerson HJ, Holubets MC, Weiler BR, et al. Causes of iron deficiency in adolescent athletes. J Pediatr 1989; 114: 657–63
Nickerson HJ, Holubets M, Tripp AD, et al. Decreased iron stores in high school female runners. Am J Dis Child 1985; 139: 1115–9
Rowland TW, Kelleher JF. Iron deficiency in athletes: insights from high school swimmers. Am J Dis Child 1989; 143: 197–200
Rowland TW, Stagg L, Kelleher JF. Iron deficiency in adolescent girls: are athletes at increased risk? J Adolesc Health 1991; 12: 22–5
Lampe JW, Slavin JL, Apple FS. Iron status of active women and the effect of running a marathon on bowel function and gastrointestinal blood loss. Int J Sports Med 1991; 12: 173–9
Weight LM, Jacobs P, Noakes TD. Dietary iron deficiency and sports anemia. Br J Nutr 1992; 68: 253–60
Magnusson B, Hallberg L, Rossander, et al. Iron metabolism and ‘sports anemia’: II. A hematological comparison of elite runners and control subjects. Acta Med Scand 1984: 216: 157–64
Wishnitner R, Vorst E, Berrebi A. Bone marrow iron depression in competitive distance runners. Int J Sports Med 1983; 4: 27–30
Haymes EM, Spillman DM. Iron status of women distance runners, sprinters, and control women. Int J Sports Med 1989; 10: 430–3
Moses FM. Gastrointestinal bleeding and the athlete. Am J Gastroenterol 1993; 88: 1156–9
Baska RS, Moses FM, Graeber G, et al. Gastrointestinal bleeding during an ultramarathon. Dig Dis Sci 1990; 35: 276–9
Cianflocco AJ. Renal complications of exercise. Clin Sports Med 1992; 11: 437–51
Weight LM, Byrne MJ, Jacobs P. Haemolytic effects of exercise. Clin Sci 1991; 81: 147–52
Nattiv A, Puffer J. Lifestyles and health risks of collegiate athletes. J Fam Pract 1991; 33: 585–90
Brune M, Magnusson B, Persson H, et al. Iron losses in sweat. Am J Clin Nutr 1986; 43: 438–43
Rowland TW. Iron deficiency in the young athlete. Pediatr Clin North Am 1990; 37: 1153–63
Finch CA, Miller LR, Inamdar AR, et al. Iron deficiency in the rat. J Clin Invest 1976; 58: 447–53
Newhouse IJ, Clement DB, Taunton JE, et al. The effects of prelatent/latent iron deficiency on physical work capacity. Med Sci Sports Exerc 1989; 21: 263–8
Celsing F, Blomstrand E, Werner B, et al. Effects of iron deficiency on endurance and muscle enzyme activity in man. Med Sci Sports Exerc 1986; 18: 156–61
Matter M, Stittfall T, Graves J, et al. The effect of iron and folate therapy on maximal exercise performance in female marathon runners with iron and folate deficiency. Clin Sci 1987; 72: 415–22
Raunikar RA, Sabio H. Anemia in the adolescent athlete. Am J Dis Child 1992; 146: 1201–5
Jones SR, Binder RA, Donowho EM. Sudden death in sickle cell trait. N Engl J Med 1970; 282: 323–5
Phillips M, Robinowitz M, Higgins JR, et al. Sudden cardiac death in air force recruits. JAMA 1986; 256: 2696–9
Hoiberg A, Ernst J, Uddin DE. Sickle cell trait and glucose-6- phosphate dehydrogenase deficiency. Arch Intern Med 1981; 141: 1485–8
Kark JA, Posey DM, Schumacher HR, et al. Sickle-cell trait as a risk factor for sudden death in physical training. N Engl J Med 1987; 317: 781–7
Eichner ER. Sickle cell trait, heroic exercise, and fatal collapse. Physician Sports Med 1993; 21 (7): 51–64
Browne RJ, Gillespie CA. Sickle cell trait: a risk factor for life-threatening rhabdomyolysis? Physician Sports Med 1993; 21 (6): 80–8
Eichner ER. Sickle cell trait, exercise, and altitude. Physician Sports Med 1986; 14 (11): 144–57
Heller P, Best WR, Nelson RB, et al. Clinical implications of sickle-cell trait and glucose-6-phosphate dehydrogenase deficiency in hospitalized black male patients. N Engl J Med 1979; 300: 1001–5
Kark JA, Ward FT. Exercise and hemoglobin S. Sem Hematol 1994; 31: 181–225
Le Gallais D, Prefaut C, Dulat C, et al. Sickle cell trait in ivory coast athletic champions, 1956–1989. Int J Sports Med 1991; 12: 509–10
Murphy JR. Sickle cell hemoglobin (Hb AS) in black football players. JAMA 1973; 225: 981–2
Le Gallais D, Prefaut C, Mercier J, et al. Sickle cell trait as a limiting factor for high-level performance in a semi-marathon. Int J Sports Med 1994; 15: 399–402
Pace N. The increase in hypoxia tolerance of normal men accompanying the polycythemia induced by transfusion of erythrocytes. Am J Physiol 1947; 148: 152–63
Ekblom B, Goldbarg AN, Gullbring B. Response to exercise after blood loss and reinfusion. J Appl Physiol 1972; 33: 175–80
Williams MH, Wesseldine S, Somma T, et al. The effect of induced erythrocythemia upon 5-mile treadmill run time. Med Sci Sports Exerc 1981; 13: 169–75
Buick FJ, Gledhill N, Froese AB, et al. Effect of induced erythrocythemia on aerobic work capacity. J Appl Physiol 1980; 48: 636–42
Brien AJ, Simon TL. The effects of red blood cell infusion on 10-km race time. JAMA 1987; 257: 2761–5
Ekblom B, Berglund B. Effect of erythropoietin administration on maximal aerobic power. Scand J Med Sci Sports 1991; 1: 88–93
Eichner ER. Better dead than second. J Lab Clin Med 1992; 120: 359–60
Wide L, Bengtsson C, Berglund B, et al. Detection in blood and urine of recombinant erythropoietin administered to healthy men. Med Sci Sports Exerc 1995; 27: 1569–76
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Shaskey, D.J., Green, G.A. Sports Haematology. Sports Med 29, 27–38 (2000). https://doi.org/10.2165/00007256-200029010-00003
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-200029010-00003