Establishment of Blood Screening Protocols for Collegiate Endurance Athletes

Establishment of Blood Screening Protocols for Collegiate and Endurance Athletes

The goal of this action research proposal is to establish blood screening for endurance athletes at the college, which the researcher is employed at as there is currently no system in place by which the athletic department, athletic training room, and health center work together to screen athletes that exhibit symptoms of non-anemic iron deficiency.

The standard testing protocols to determine anemia at most health centers do not adequately diagnose non-anemic iron deficiency in elite endurance athletes.

There is a need for standard testing protocols at the college health centers for accurate diagnosis of non-anemic iron deficiency in elite endurance athletes.

Literature Review

The work of Eichner (2001) entitled "SSE #81: Anemia and Blood Boosting" states that athletes, "especially endurance athletes, tend to have slightly low hemoglobin levels as judged by general population norms." Eichner reports that low blood hemoglobin concentration "…defines anemia, this has been called sports anemia. But sports anemia is a misnomer because in most such athletes -- especially men -- the low hemoglobin level is a false anemia. The total volume of red cells in the body is normal, not low. Hemoglobin level is decreased because aerobic exercise expands the baseline plasma volume; this reduces the concentration of red cells, which contain the hemoglobin. In other words, the naturally lower hemoglobin level of an endurance athlete is a dilutional pseudoanemia." (Eichner, 2001) Pseudoanemia is stated to be "…an adaptation to hemoconcentration that occurs during workouts. Vigorous exercise acutely reduces plasma volume by 10-20% in three ways. One, a rise in blood pressure and muscular compression of venules boost the fluid pressure inside the capillaries of the active muscles. Two, generation of lactic acid and other metabolites in muscle increases tissue osmotic pressure. These forces drive plasma fluid, but not red cells, from blood to tissues. Three, some plasma water is lost in sweat." (Eichner, 2001) Renin, aldosterone and vasopressin are released which conserve water and salt. In addition, albumin is added to the blood. The result is that baseline plasma volume expands and even one single round of intense exercise may expand the plasma volume up to 10% in a 24-hour period. (Eichner, 2001) According to Eichner it is common for an endurance athlete to have a hemoglobin concentration of "1 g/dL or even 1.5 g/dL below 'normal'." (2001) The recognition of this as pseudoanemia is dependent on the setting as well as exclusion of other anemias. Plasma volume changes quickly depending on the level of exercise therefore athletes who are in training the most have the lowest levels of hemoglobin's when daily workouts cease they have a rising hemoglobin level. Stated as key to aerobic fitness is pseudonanemia since the rise in plasma volume in addition to the athlete's heart adapting increasing the cardiac stroke volume which is stated to compensate for the fall in the concentration of hemoglobin per unit of blood which results in more oxygen being delivered to the muscles. Sports anemia is reported to be a false anemia and it is stated that exertional hemolysis nearly never causes anemia therefore iron deficiency is the leading cause of anemia in athletes and as well is reported to be a common cause of fatigue in female athletes. Insufficient can lead to low hemoglobin as it is a "critical component of hemoglobin." (Eichner, ) Eichner (2001a) reports that patients with anemia "feel fatigued only with exertion." When anemia is mild in nature, Eichner reports that the only thing that will unmask the anemia is strenuous exercise. Eichner and Scott (1998) report

"This was the case in three college athletes, all initially difficult to diagnose (Eichner & Scott, 1998). One was an elite runner who began losing races. Another was a softball player who saw a cardiologist for spells of fast heartbeat and breathlessness in training. The third was a basketball player who fell behind in training and was called an underachiever. In each case, the culprit was loss of stamina from iron deficiency anemia." (Eichner and Scott, 1998)

Reported as well by Eichner (2001) is that in a recent survey of 25,000 individuals in the United States findings show that 10% of young women are iron deficient and another 3 to 5% of young women are anemic. Iron deficiency among young men is reported to be rare. The survey is stated to have "…defined anemia in women as hemoglobin 12 g/dL were given iron or placebo for 6 weeks as they trained. Those on iron grew fitter and cycled faster. Hemoglobin tended to rise on iron, and this rise improved "energetic efficiency." Conclusion: Women with hemoglobin >12 g/dL may be "functionally anemic." (Hinton, et al., 2000 in Eichner, 2001) Reported as well is that researchers "…also gauged VO2 max in two groups of young women called "nonanemic" because hemoglobin was >12 g/dL (Zhu et al., 1997). One group was iron depleted (ferritin 12 g/dL, they were anemic compared to the iron-replete women." (Eichner, 2001) Anemia is stated to be "relative" in that in the studies described "…slight differences in hemoglobin levels, all >12 g/dL, affected athletic performance. Anemia is best defined as a subnormal hemoglobin level for the individual. For example, a female athlete with hemoglobin 13 g/dL is anemic if her normal value is 14 g/dL. No firm cutoff value defines anemia." (Eichner, 2001) Iron deficiency anemia is reported to be "more common than surveys suggest. The more an athlete asks of her body, the more likely she is to feel exertional fatigue if she has mild anemia. Because of this, female athletes can benefit from regular screening. At the University of Oklahoma, we screen all female athletes yearly for hemoglobin and ferritin. We find up to 10-20% or more of first-year female athletes iron deficient. Many of these are anemic, some with hemoglobin 12 g/dL." (Eichner, 2001) It is reported that the iron deficiency was found in 20% of varsity female volleyball and basketball players with hemoglobin

The work of Fallon ( ) entitled "Utility of Hematological and Iron-Related Screening in Elite Athletes" reports that a paucity of prospective studies exist related to the utility of screening of hematological and iron-related variables in elite athlete populations. Hematological and iron-related variables have been documented in athletes participating in a wide variety of sports, but the clinical and performance-related significance of screening results in elite populations has not been documented." (Fallon, ) It is reported that in two large studies of preparticipation health screening that there was no mention of blood analysis and it was not included in the evaluation. Reported as well is that only one study reported having "conducted retrospectively in 1067 college athletes, assessed the value of screening for hematological variables. The authors measured white blood cell count (WCC), hemoglobin, mean corpuscular volume (MCV), and platelet count in both males and females and concluded that the only useful test was that for hemoglobin. The aspect of hematological and biochemical screening that is most justifiable is that of anemia. In athletes, as in the general population, anemia is most frequently associated with iron deficiency." (Fallon, )

Garza et al. (1997) tested the clinical value of serum ferritin tests in endurance athletes and concluded that "the literature does not justify routine measurement of ferritin as an independent marker of endurance performance in athletes." (Fallon, ) However, more recent evidence is stated by Fallon to call this conclusion into question as Hinton et al. In reports a double-blind, placebo-controlled trial, that investigated the effect of iron supplementation in 42 iron-depleted nonanemic women. Findings of the study state that five male athletes were identified in which "screening abnormalities were associated with illness or other factors that explained the abnormalities." ( ) In three cases it is reported that hematological screening did not contribute clinically useful data as the abnormalities would have been expected based on the history and examination." In the other two it is reported that "the case of the asymptomatic slowly developing iron deficiency and of the football player who refused follow-up, hematological and iron-related screening uncovered clinically useful information." ( )

Finally in regards to male athlete screening the study reports "In summary, the screening blood tests carried out on this group of elite male athletes found only 2 sets of abnormalities of clinical significance that could not have been suspected from clinical history and examination. Five athletes with a serum ferritin less than 30 ng/mL satisfied our criteria for iron supplementation. These were the only cases in which a change in athlete management was made based solely on blood test results." ( ) Findings in regards to the female athletes state that six cases were identified "in which screening abnormalities were associated with illness or other factors that explained the abnormalities. In each case, hematological screening would not have been useful as the abnormalities would have been expected based on the history and examination. Two others required further investigation. Twenty-seven athletes were identified as candidates for iron supplementation (ferritin

One change methodology is that of Leadership that 'leads by example' and it is reported in the work of Nellis ( ) that the leader must know themselves and know their people. In order to compel all actors to buy-in to the change initiative it is important to have knowledge of the staff and moreover to know what motivates each individual and for example knowing what motivates each individual, that individual's needs. There are three other people skills stated to be vital to successful management or leadership which are those of: (1) enacting loyalty; (2) encouragement; and (3) reprimand. ( ) It is related that loyalty is a requirement for successful organizations. Stated as well is that positive opportunities ensure exposure to all facts of athletic training.

Change management is focused on achieving organizational efficiency and has as its bases the work of Kurt Lewin. Kurt Lewin proposed a 'force field analysis model for use in understanding organizational change. Force field analysis proposes that an organization is typically in a state of equilibrium." (Change Management, 2002) There are two forces that maintain organizational stability; driving forces and restraining forces. Driving forces are stated to be those elements of the organization which support a desired organizational change. Keeping the organization in equilibrium are the restraining forces becomes stronger than the other (disequilibrium) Once the change has occurred the organization is reported to revert "to a new state of equilibrium which reflects the desired change." (JPC Training and Consulting, 2002) Lewin's model when followed to a logical conclusion is stated to predict that an intervention which strengthens the driving forces or weakens the restraining forces will result in the desired change. Intervention strategies different from author to author but they contain similar elements. The following are reported to be basic elements of a formula-based organizational change strategy:

(1) Determination of the need to change;

(2) Development of a vision;

(3) Consensus building;

(4) Indentify barriers to implementation;

(5) Walk the talk;

(6) Creating an overall change strategy;

(7) Implementation and evaluation. (JPC Training and Consulting, 2002)

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Peter Senge (1999) explored the "art and practice of the learning organization" with more than 750,000 copies of The Fifth Discipline were sold in the ten years after it was first published. Three definitions of a learning organization are stated as follows: (1) Learning organizations are those in which people expand their capacity to create the results they want in an ongoing manner and where "new and expansive patterns of thinking are nurtured, when collective aspiration is set free, and where people are continually learning to see the whole together." (Senge 1990: 3 cited in: Smith, 2001)