Student-Athlete Advocacy Project

Test Your Metal

A $14 blood test the sports physical never orders.

About 1 in 3 female athletes is iron deficient. It drags down performance, clouds concentration, and drains energy. Left long enough, it can do lasting harm. Most cases are missed because the standard sports physical does not include a single blood test. We want that to change.

See What We're Asking For My Experience

1 in 3

female college athletes are iron deficient (30.9% deficient without anemia, ferritin <20 ng/mL) Parks et al., Med Sci Sports Exerc, 2017

84%

of iron-deficient US girls and young women are not anemic. A standard blood count misses them Weyand et al., JAMA, 2023

38.6%

of US females aged 12–21 are iron deficient (ferritin <25 µg/L) Weyand et al., JAMA, 2023

$14

what Medicare pays for a ferritin test; cash-pay prices usually run $23–$59 CMS Clinical Laboratory Fee Schedule, CPT 82728

15 mg

daily iron RDA for girls 14–18 (18 mg at 19+). Athletes are advised to aim higher, and most girls fall short NIH Office of Dietary Supplements

states that require any blood test in a high school sports physical PPE Monograph, 5th ed.; state athletic association forms

The Problem

A common condition, and almost nobody looks for it

Iron deficiency is one of the most common nutritional deficiencies in the United States, and adolescent girls are among the most affected groups. The CDC estimates that roughly 1 in 8 US women aged 12 to 49 is iron deficient, and low ferritin in women of reproductive age has been rising for two decades. Among female college athletes, about 1 in 3 is iron deficient.

Yet the annual sports physical (often the only medical appointment a healthy teenager has all year) includes no blood test at all.

Menstruation and hard training both cost iron

Monthly blood loss draws down iron stores. Training raises the demand at the same time: iron sits at the center of hemoglobin and myoglobin, the proteins that carry and store the oxygen your muscles run on. Athletes also lose iron through sweat, footstrike damage to red blood cells, and the gut. And inflammation from hard exercise temporarily blocks absorption of the iron you eat.

You don't have to be anemic to be affected

Anemia is the last stage of iron deficiency, not the whole of it. Endurance, recovery, concentration, and mood can all suffer while hemoglobin is still normal. In US girls and young women who are iron deficient, 84% are not anemic, which means a routine blood count would clear them. Studies show that treating iron-depleted, non-anemic athletes measurably improves how they perform.

The symptoms get explained away

Fatigue, slow recovery, brain fog, and heavy legs are routinely written off as overtraining, stress, or “just being a teenager.” Because the explanation sounds reasonable, the real cause can go unfound for years.

The sports physical doesn't look

The national pre-participation physical evaluation is a health history and a physical exam. No state high school association requires hemoglobin, hematocrit, or ferritin. Sports medicine groups have argued that routine labs aren't justified for athletes with no symptoms, a reasonable position if you assume that the symptoms of iron deficiency are recognized when they appear. But they frequently aren't.

My Story

I lived it, and I don't want anyone else to

I am a student-athlete entering my senior year in high school. I have played high-levrel club soccer since I was 5, and high-school soccer the last three years. I was always fast, fit and reliable. I never missed practice or games, and never came off the field.

But during my sophomore year, I began to struggle. I got slower. I was tired all the time. I lost focus. By winter, I couldn't make it through a single training session without overwhelming fatigue. In the spring, I got taken out of games because I couldn't keep up. For the first time in my life, soccer wasn't fun.

And soccer wasn't the only thing I fell behind in. I couldn't concentrate in class or keep up with my work. My grades dropped. I spent less time with friends, and I lost out on countless moments. I was sleeping ten hours a night, but I still struggled to stay awake or even feel like myself.

Everyone was worried - my parents, my coaches, my teammates - even my teammates parents! I was told I needed to work harder, eat more, eat better, manage my stress.

My doctor suggested I take a few weeks off. And I did. But when I came back worse my coach said I needed to go to the hospital and they finally ordered a simple blood test that revealed what was really going on: I had severe iron-deficiency anemia. I had been running my life on a ferritin level of 3 ng/mL and a hemoglobin level of 4 g/dL. For reference, iron deficiency is generally defined as ferritin below 30 ng/mL, and normal hemoglobin for women is roughly 12 to 16 g/dL.

I was rushed to the ER, given a transfusion and an IV bag full of iron. Two weeks later, I felt like a completely different person. I felt like myself again. But because nobody suggested I get my iron levels tested, I lost a whole year of school and soccer.

When I told my friends and teammates about what happened, I found out that lots of them - especially female athletes - struggle with the same thing. I learned that the test used to be a part of the annual physicals you have to take before playing high school sports. I want them to add it back, but until they do, I want everyone to know how important and how easy it is to get your iron levels tested.

Stella Eisen, Soccer Player

What We're Asking For

Three simple, low-cost changes

We want schools and physicians to make iron status part of the conversation about whether an athlete is ready to compete.

Restore ferritin testing in the sports physical

Every female athlete should leave her annual physical having been asked about fatigue, periods, and diet, and offered a serum ferritin test alongside a complete blood count. Not a universal mandate for every patient, but a default offer for menstruating athletes. In 2026 the American Academy of Pediatrics went further, recommending screening with a blood count and ferritin for all adolescents at least one year past their first period. The sports physical is where many girls would actually be reached.

Use a threshold that means something

Many labs only flag ferritin as “low” in the single digits, well beneath the level where athletes start feeling it. A ferritin at or below 30 ng/mL should prompt a follow-up conversation with a clinician. One caution: ferritin rises with infection, injury, and inflammation, so a borderline result taken during illness or right after a hard block of training can look falsely reassuring and is worth repeating.

Teach athletes, families, and coaches what to look for

Screening only helps if someone acts on it. Give athletes, parents, and coaches the signs, the risk factors, and the basics of iron in food, so early symptoms get recognized instead of rationalized.

The Evidence

The research behind this is decades deep

Here are the findings we lean on most:

In a nationally representative sample of US females aged 12 to 21, 38.6% were iron deficient, and 84% of them were not anemic. Screening on hemoglobin alone would have missed the large majority. Weyand et al., JAMA, 2023

Across 12 years of blood draws at a Division I athletics program, 30.9% of female athletes were iron deficient without anemia and 2.2% had iron-deficiency anemia. Parks, Hetzel & Brooks, Medicine & Science in Sports & Exercise, 2017

Iron-depleted but non-anemic women showed impaired aerobic adaptation to training; iron supplementation improved it, showing that low iron costs you something well before it becomes anemia. Brownlie et al., American Journal of Clinical Nutrition, 2004

Female collegiate rowers who were iron-depleted without anemia performed measurably worse on a 4 km time trial at the start of the season than their iron-sufficient teammates. DellaValle & Haas, International Journal of Sport Nutrition and Exercise Metabolism, 2011

Hard exercise raises hepcidin, a hormone that shuts down iron absorption, with levels peaking roughly three hours after training. Athletes are therefore working against their own physiology when they try to fix low iron through diet alone. Sim et al., European Journal of Applied Physiology, 2019

The International Olympic Committee's consensus statement on Relative Energy Deficiency in Sport treats iron status as a health parameter that should be monitored in at-risk athletes. Mountjoy et al., IOC Consensus Statement on REDs, British Journal of Sports Medicine, 2023

The recommended iron intake for girls aged 14 to 18 is 15 mg per day, rising to 18 mg at 19. Sports nutrition guidance advises athletes to aim above the RDA, since intense training can raise requirements by roughly 30% to 70%. Most adolescent girls do not reach even the baseline figure. NIH Office of Dietary Supplements; Academy of Nutrition and Dietetics / ACSM joint position stand, 2016

Know the Signs

What iron deficiency actually looks like

None of these symptoms proves iron deficiency on its own, and all of them have other explanations. But if several show up together, especially alongside heavy periods or a training load that suddenly feels impossible, it is worth asking a doctor for a blood count and a ferritin test.

What you might see

Pale skin, or loss of color in the inner eyelids, gums, and nail beds
Brittle or spoon-shaped nails, hair thinning, cracks at the corners of the mouth
Cold hands and feet when nobody else is cold
Heavy or prolonged periods
Restless legs at night, or cravings for ice, dirt, or starch

What you might feel

Fatigue or weakness out of proportion to your training
Headaches, dizziness, feeling lightheaded on standing
Trouble concentrating, low mood, irritability
Getting out of breath or hitting a racing heart rate at efforts that used to feel easy
Chest pain: this one warrants same-day medical attention

Eating for iron

Food is where prevention starts. Iron comes in two forms: heme iron from animal sources, which the body absorbs relatively well, and non-heme iron from plants and fortified foods, which is absorbed less efficiently but still adds up.

Heme iron

Shellfish (clams, oysters, mussels), red meat (beef, bison, lamb), liver and other organ meats, sardines, turkey and chicken - especially the dark meat.

Non-heme iron

Legumes (lentils, chickpeas, black beans, kidney beans), soy foods (tofu, tempeh, edamame), seeds and nuts (pumpkin, sesame, cashews), dark leafy greens, dried apricots, blackstrap molasses, and fortified cereals and breads. Cereal fortification varies a lot, from around 10% of the Daily Value per serving to 100%. Check the label rather than assuming.

Help absorption

Pair non-heme iron with vitamin C: peppers, citrus, tomatoes, strawberries, broccoli. A little heme iron in the same meal helps too. Cooking in cast iron adds a small amount.

Watch the blockers

Tea, coffee, calcium and dairy, and calcium supplements all reduce iron absorption when taken with a meal. Space them out rather than cutting them, and note that the greens highest in iron, like spinach, also contain oxalates that limit how much of it you actually take up.

Test before you supplement

Iron supplements are not a harmless guess. Your body has no easy way to get rid of excess iron, some people carry genetic conditions that make loading dangerous, and iron pills are a leading cause of poisoning in young children. Get a ferritin test first, then let a clinician set the dose and follow-up. If you do need iron, ask about taking it every other day and away from tea, coffee, and calcium. This can improve how much you actually absorb.

Take Action

What you can do

This change does not require new technology or much money. It requires people to ask one more question.

If you're a student-athlete

If any of the symptoms above sound like you, ask your doctor for a ferritin test at your next physical. Talk to your teammates about iron. If you have been through this, share your story - it travels further than statistics do.

If you're a parent

Ask your child's pediatrician about a ferritin test, especially for a menstruating athlete in an endurance sport. Learn the signs, and pass them on to other parents on the team.

If you're a coach or trainer

Learn the signs well. When an athlete's performance drops or her fatigue seems out of proportion to her training, encourage her to get her iron checked. A coach is the reason I found out.

If you're an administrator

Add ferritin screening guidance to your district's athletic physical materials, and help make low-cost testing available locally. We would love to talk through the logistics with you.

Get in Touch Read the Research

Resources

Learn more

NIH Iron Fact Sheet

Comprehensive overview of iron requirements, deficiency, and health effects from the Office of Dietary Supplements.

Read at NIH.gov →

Iron Deficiency in US Adolescent Females

The JAMA research letter showing that most iron-deficient girls and young women are not anemic, so hemoglobin-only screening misses them.

Read at JAMA →

Iron Deficiency in College Athletes

Twelve years of screening data from a Division I program, and the source of the 1-in-3 figure.

Read at PubMed →

Iron and Endurance Performance

The Brownlie et al. study showing that iron depletion impairs aerobic adaptation even without anemia.

Read at AJCN →

Iron Considerations for Athletes

A narrative review of iron metabolism, loss mechanisms, hepcidin, and management in athletes.

Read at EJAP →

IOC REDs Consensus (2023)

The IOC's current framework for energy deficiency in sport, including iron status monitoring.

Read at BJSM →