Does Iron Supplementation Improve Performance in Iron-Deficient Nonanemic Athletes?

Context: Supplementing iron-deficient nonanemic (IDNA) athletes with iron to improve performance is a trend in endurance sports. Objectives: To investigate the benefits of iron on performance, identify a ferritin level cutoff in IDNA athletes, and determine which iron supplementation regimens are most effective. Data Sources: A search of the PubMed, CINAHL, Embase, ERIC, and Cochrane databases was performed in 2014 including all articles. Citations of pertinent review articles were also searched. In 2017, the search was repeated. Study Selection: Inclusion criteria comprised studies of level 1 to 3 evidence, written in the English language, that researched iron supplementation in nonanemic athletes and reported performance outcomes. Study Design: Systematic review. Level of Evidence: Level 3. Data Extraction: The search terms used included athletic performance, resistance training, athletes, physical endurance, iron, iron deficiency, supplement, non-anemic, low ferritin, ferritin, ferritin blood level, athletes, and sports. Results: A total of 1884 studies were identified through the initial database search, and 13 were identified through searching references of relevant review articles. A subsequent database search identified 46 studies. Following exclusions, 12 studies with a total of 283 participants were included. Supplementing IDNA athletes with iron improved performance in 6 studies (146 participants) and did not improve performance in the other 6 studies (137 participants). In the 6 studies that showed improved performance with iron supplementation, all used a ferritin level cutoff of 20 g/L for treatment. Additionally, all studies that showed improved performance used oral iron as a supplement. Conclusion: The evidence is equivocal as to whether iron supplementation in IDNA athletes improves athletic performance. Supplementing athletes with ferritin levels <20 g/L may be more beneficial than supplementing athletes with higher baseline ferritin levels.