The undersigned, appointed by the Vice President of the Graduate School, have examined the dissertation entitled: Iron Deficiency and Endurance Athletes by: Jamin Swift A candidate for the degree of Doctor of Education And hereby certify that in their opinion it is worthy of acceptance April 2018 Approved: Chair: __________________________________________________________________ (Dr. Paul Sturgis, Ed. D, Chair) __________________________________________________________________ (Dr. Doug Ebersold, Ed. D, Committee Member) __________________________________________________________________ (Dr. Lynn Hanrahan, Ed. D, Committee Member) __________________________________________________________________ (Dr. J. Michael Pragman, Ed. D, Committee Member) Iron Deficiency and Endurance Athletes by Jamin Swift A Dissertation Presented to the Faculty of the Graduate College William Woods University in Partial Fulfillment of the Requirement for the Degree Doctor of Education May 2018 3 Abstract The purpose of this study was to explore the various opinions concerning the importance of testing multiple markers of iron status while examining the current knowledge base in relation to the effects of iron depletion on endurance athletes. Contrasting beliefs exist pertaining to the differing methods for screening iron status as well as differing opinions regarding healthy ranges on those assessments. This study utilized an exploratory research approach to determine which diagnostic tests physicians deem most beneficial in determining iron deficiency in endurance athletes. Employing semi-structured personal interviews to twelve coaches and six healthcare professionals along with open-ended surveys to eight athletes and eight parents, this study collected qualitative data from 34 participants regarding current doctor recommendations toward the diagnosis of non-anemic iron deficiency, the importance of serum ferritin tests, and effective forms of treatment. Through a process of open and axial coding, four distinct themes emerged in relation to testing iron levels of fatigued endurance athletes: contact a healthcare professional, serum ferritin is an important test, creation of optimal ranges, and treatment options. According to this study, within the first two weeks of noticing persistent fatigue, athletes should seek the opinion of a healthcare professional due to the possibility of underlying disease and risks associated iron overload. Due to the prevalence of depleted iron stores within this demographic, participants in this study claimed that serum ferritin is an important test associated 4 with persistent fatigue reported by endurance athletes. Pertaining to blood tests associated with fatigue, participants in this study expressed that normal ranges need to be refined and optimal ranges need to be developed to promote optimal performance instead of minimal requirements. Lastly, participants in this study reported that treatment options are generally easy, affordable, and effective in the absence of underlying disorders or disease. This study also confirmed a large disconnect between the opinions expressed by the healthcare professionals of this study and the experiences reported by the coaches, athletes, and parents with primary care physicians. Many of the coaches, athletes, and parents reported poor experiences with their primary care physicians where they often had to self-advocate and demand additional iron tests not included with the standard CBC. The implications of this study will be extremely beneficial as it provides educational information and critical resources for use in conversations with primary care physicians related to iron depletion. 5 Dedication This dissertation is dedicated to my closest friends and family, and to the memory of my grandparents: Virgil Thomas, Elsie Thomas, George Swift, and Harriet Swift. Without their constant love, support, understanding, and virtues they’ve passed on to so many generations, I’m not sure I would have crossed this finish line. 6 Acknowledgements An endeavor of this nature requires the assistance and support of numerous individuals. This research would not have been possible without the assistance and guidance from the professors at William Woods University and support from my incredible colleagues, friends, and family members. I am thankful for each and every individual that has impacted this study directly or indirectly. Words cannot express the true appreciation and love I have for each of you. Specifically, I would like to thank my committee chair, Dr. Paul Sturgis, for his support and quick responses to my never-ending questions during this adventure. I would also like to thank Dr. Michael Pragman for his expertise and guidance pertaining to the challenges of qualitative analysis. I sincerely appreciate the continued support and timely feedback you both offered through all the difficulties posed in a study of this nature. I would also like to thank my closest friends and family, near and far. I cannot express how important they have been to me in the pursuit of this endeavor. Your kind words in person and through social media have impacted me more than you will ever know. I would like to thank my parents for being great role models and always supporting me throughout all of life’s challenges. Most of all, I would like to thank my son, Tyler, for his constant encouragement, his incredible patience, and his understanding when this project monopolized my time and took me away from the person I love most. Love you most! 7 Table of Contents List of Tables ................................................................................................... 11 Chapter One - Introduction .............................................................................. 12 Background of Study ................................................................................. 12 Statement of Problem ................................................................................ 13 Purpose of Study ....................................................................................... 13 Significance of Study ................................................................................ 14 Definition of Terms ................................................................................... 14 Research Questions ................................................................................... 16 Limitations ................................................................................................. 16 Delimitations ............................................................................................. 17 Assumptions .............................................................................................. 17 Organization of the Study .......................................................................... 17 Chapter Two - Review of Literature ............................................................... 19 Introduction ............................................................................................... 19 Scientific Background and Definitions ..................................................... 20 Iron and Its Importance to Endurance Athletes ......................................... 22 Relevance to endurance athletes .................................................... 22 Oxygen delivery and cellular respiration. ......................... 22 Oxygen delivery and VO2 max. ........................................ 24 Iron depletion associated with endurance athletes ........................ 26 Symptoms and effects of iron deficiency. ..................................... 31 Importance of monitoring dietary intake. ...................................... 32 8 Diagnosis of Iron Deficiency .................................................................... 33 Importance of screening. ............................................................... 33 Methods of diagnosis. .................................................................... 36 Three stages of iron deficiency. .................................................... 43 Iron depletion. ................................................................... 43 Iron deficient non-anemic. ................................................ 44 Iron deficiency anemia. ..................................................... 45 Classifications of anemia. .............................................................. 46 Need for standardization. .............................................................. 48 Supplementation ........................................................................................ 52 Determining the need for dietary supplements. ............................. 52 Types of treatment. ........................................................................ 54 Benefits and risks associated with treatments. .............................. 57 Conclusion ................................................................................................. 60 Chapter Three - Research Methodology ......................................................... 65 Introduction ............................................................................................... 65 Selection of Participants ............................................................................ 65 Instrumentation .......................................................................................... 66 Role of the Researcher .............................................................................. 67 Data Collection .........................................................................................