Iron Deficiency as a Flag for the Female Athlete Triad

The female athlete Triad (Triad) is defined as low energy availability (low EA) with or without an eating disorder, menstrual dysfunction, and low bone mineral density (BMD). On average, 78% of female athletes display at least one Triad component, 27% exhibit two components, and 16% exhibit all three components. Although prevalence in this population is high, the Triad is often undiagnosed. If left untreated, the Triad can lead to long-term health consequences such as osteoporosis, impaired fertility, arrhythmias, and hormone dysfunction. The severe health consequences associated with untreated Triad symptoms give reason to explore improved Triad screening techniques. Recent studies have suggested that low-iron status may serve as an objective clinical marker for low EA, the main driver of the Triad. Iron deficiency is the most common nutrient deficiency in athletes, with female athletes at an even higher risk due to monthly menstruation. Iron deficiency may serve as a proxy for low EA in female athletes, assisting in the diagnosis of the Triad. A search for recent literature regarding the Triad and iron status was conducted on the search engine PubMed.gov using the search terms Triad, iron, anemia, low EA, and female athletes. This is a review of three papers that examines the possible relationship between the Triad and low-iron status. Dellavalle, et al. (2022) studied the potential link between iron depletion without anemia (IDNA) and performance in a cohort of 165 female rowers from 5 universities. Rowers with normal iron status trained 10 mins longer per day on average and had a higher VO2 max. Serum ferritin (Sfer) and training group were positively related to VO2 max. The relationship between rowers' iron status and endurance performance varied depending on their training load. IDNA may prevent rowers from training as hard. Finn, et al. (2022) investigated whether markers of low-iron status could be related to Triad risk factors in a cohort of 239 female National Collegiate Division I athletes. Every Triad risk component (excluding delayed menarche) was associated with low-iron status. Lean/endurance athletes were more likely to have low-iron status than other athlete types. Hooper, et al. (2021) tracked a population of female collegiate runners from pre-cross-country season (Pre XC) to post-cross-country season (Post XC) and pre-track season (Pre Track). They concluded that changes observed with low EA may be complex and impossible to evaluate with a single biomarker such as iron. This study shows the potential ability of reduced resting metabolic rate (RMR) to detect concerns related to the Triad. Further investigation is warranted to determine whether low EA is the driver of low-iron status and thus could be used as an objective marker for the Triad in female athletes.Hudson, ErinNutritional Science