Point:Counterpoint: Sickle cell trait should/should not be considered asymptomatic and as a benign condition during physical activity

Abstract

POINT-COUNTERPOINTPoint:Counterpoint: Sickle cell trait should/should not be considered asymptomatic and as a benign condition during physical activityDaniel Le Gallais, Jean Lonsdorfer, Pascal Bogui, and Slaheddine FattoumDaniel Le Gallais, Jean Lonsdorfer, Pascal Bogui, and Slaheddine FattoumPublished Online:01 Dec 2007https://doi.org/10.1152/japplphysiol.00338.2007This is the final version - click for previous versionMoreSectionsPDF (44 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations POINT: SICKLE CELL TRAIT SHOULD BE CONSIDERED ASYMPTOMATIC AND AS A BENIGN CONDITION DURING PHYSICAL ACTIVITYSickle cell trait (SCT) is found in ∼8% of African Americans and may be found in up to 40% of West Africans. However, most of them are unaware of their status. This observation suggests that SCT may be asymptomatic and remains a benign condition for daily life activities (5). Indeed, numerous studies have reported that subjects with SCT had normal growth and development, normal morbidity (10) and mortality (21), and finally, normal life expectancy (12). Moreover, in worldwide countries of malarial endemicity, subjects with SCT have been found to be more healthy and able to perform heavy physical labor than subjects without the trait. Our hypothesis that SCT can also be considered asymptomatic and as a benign condition during physical activity is based on five kinds of data.1) Epidemiological studies on large popular sporting events.Of 1,506 black males participating in the first Abidjan semi-marathon, SCT was detected in 123, i.e. 8.7%, a percentage similar to that observed in the general Ivory Coast population (15). Similarly, of 266 Cameroonian runners engaged in the International Mount Cameroon Ascent Race, SCT was found in 33 (12.4%), a prevalence similar to that of the ethnically corrected general population (25). These results suggest that, unlike in patients with symptoms or in an otherwise deleterious condition, there is no selective exclusion of individuals with SCT from participation in sports and physical activities.2) Epidemiological studies on specific sports practitioners.Murphy (16) reported the presence of 39 (6.7%) subjects with SCT among the black football players in the National Football League. Similarly, 15 black high school athletes with SCT (10.5%) were observed by Diggs and Flowers (7). In physical education and sports colleges in Ivory Coast and Cameroon, the prevalence of SCT was reported to be 13.7% and 18.6%, respectively, i.e.. a percentage similar to those observed in the general population of these countries (12% and 17.3%, respectively; Refs. 13, 24). These studies suggest that SCT does not discourage its carriers from practicing high level competitive activities or from engaging themselves in sports-related professions. Moreover, there are subjects with SCT among champions and record holders. Among 129 national Ivory Coast champions or record holders in races during the 1956–1989 period, we found 13 athletes with SCT (10.1%; Ref. 14). Among 122 national Ivory Coast track and field throw and jump champions during the 1956–1995 period, 34 were found to have SCT (27.8%; Ref. 3). These percentages were similar and significantly higher than subjects with SCT in the general population of Ivory Coast. Athletes with SCT participated to the 1968 Mexico Olympic Games, as reported by Pearson (17). These data indicate that athletes with SCT are quite able to perform at the highest level of long-lasting and strenuous training.3) Physical aptitude of subjects with SCT.Aerobic (maximal oxygen uptake and ventilatory threshold; Refs. 18, 27) and anaerobic (maximal anaerobic power; Ref. 2) metabolisms have been found similar in subjects with SCT and in controls with normal hemoglobin. However, blood lactate concentrations ([La]) during incremental exercise remain a controversial issue. Freund et al. (9) reported significantly higher [La] in SCT subjects than in controls. Unfortunately, these subjects exhibited significantly lower hemoglobin level than controls. In contrast, Gozal et al. (11) and Bilé et al. (3) found significant lower [La] in physical education students and sedentary subjects with SCT, respectively. Thiriet et al. (26) reported significantly lower [La] during consecutive anaerobic exercises in physical education SCT students than in controls. Recently, Sara et al. (19) took into account the different bias of the above mentioned studies and measured [La] in the blood compartments of physical education students with SCT during incremental exercise and immediate recovery. They found no significant difference in whole blood, plasma, or red blood cell [La] between SCT carriers and control subjects with normal hemoglobin. Neither the red blood cell/plasma [La] ratio nor the plasma-to-red blood cell lactate gradient differed between groups. Lactate distribution in the blood compartments did not differ between the two groups. These findings suggest that lactate production and/or clearance is quite similar during exercise in subjects with or without SCT. High [La] during exercise are associated with acidosis, which may, in turn, trigger sickle cell crisis. The observation of similar physical aptitude and similar or lower [La] in trained and untrained subjects with SCT during incremental (i.e., mainly aerobic) and anaerobic exercises is a key point to support our hypothesis that SCT should be considered asymptomatic and as a benign condition during physical activity.4) Studies on exercise tolerance in subjects with SCT.The cardiac responses to exercise in children (1) and in men and women with SCT (8) were similar to those of control subjects. Cardiopulmonary and gas exchange responses to acute strenuous exercise at low altitude (1,270 m; Ref. 27), and, at moderate inspiratory hypoxia corresponding to simulated altitude of 2,300 m (28), were found comparable in healthy, black male basic recruits with SCT and in control subjects.5) Follow-up of subjects with SCT engaged in official sports activities and military duty.During two seasons, the football and basketball squads of Melrose High School, which included students with SCT, participated in training programs and in competition without apparent disability that could be ascribed to the SCT (7). Similarly, a prospective and carefully controlled study on the effect of army basic training at an altitude of 1,270 m on SCT subjects failed to report any medical problem that could be directly attributed to SCT (29). Finally, an extensive epidemiological study on the nontraumatic deaths during U.S. armed forces basic training, 1977–2001, revealed that 26 deaths occurred in recruits with SCT. Interestingly, these 26 SCT deaths were all exercise related and due to congenital mitral valve disease, exertional heat illness, and idiopathic sudden death (20). One would thus suggest that none of the recruits with SCT died from a sickle cell crisis, i.e., due to SCT, and that the occurrence of idiopathic sudden death is inconsistent with the presence of symptoms.Overall, SCT has to be reconsidered as a single-hemoglobin gene mutation. This means that subjects with SCT are similar for this gene, but that they may be different for all other hemoglobin genes. SCT associated with alpha-thalassemia is not similar to SCT alone (22). Moreover, subjects with SCT may also be different with regard to all their remaining genes. New technologies in genomics and proteomics are revolutionizing the study of adaptation to environmental stress, particularly the adaptation to hypoxia and exercise (23). Of interest are the recent studies about the gene expression profiles of white blood cells (for the heat shock proteins) and skeletal muscle tissue in response to exercise and training stimuli, both showing many interindividual differences (5, 30). Together, these studies could explain some of the observations—exertional heat illness, training level of recruits—reported by Scoville et al. (20). Knowledge on human globin genes and their polymorphism shows that a mutation happens in a population and spreads because of its selective advantage (6). The HbS mutation occurred in regions of malaria endemicity and appeared to be, per se, asymptomatic and as a benign condition during physical activity. However, the fitness of this single mutation could depend on the genetic background of subjects when the mutation arose (6).The authors are grateful to Professor Michel Dauzat for contribution to the manuscript preparation.REFERENCES1 Alpert BS, Flood NL, Strong WB, Blair JR, Walpert JB, Levy AL. Responses to exercise in children with sickle cell trait. Am J Dis Child 136: 1002–1004, 1982.Google Scholar2 Bilé A, Le Gallais D, Mercier B, Martinez B, Ahmaidi S, Préfaut C. Anaerobic exercise components during the force-velocity test in sickle cell trait. Int J Sports Med 17: 254–258, 1996.Crossref | ISI | Google Scholar3 Bilé A, Le Gallais D, Mercier J, Bogui P, Préfaut C. Sickle cell trait in Ivory Coast athletic throw and jump champions, 1956–1995. Int J Sports Med 19: 215–219, 1998.Crossref | ISI | Google Scholar4 Browne RJ. Sickle cell trait and sudden death. Sports Med 18: 373–374, 1994.Crossref | ISI | Google Scholar5 Büttner P, Mosig S, Lechtermann A, Funke H, Mooren FC. Exercise affects the gene expression profiles of human white blood cells. J Appl Physiol 102: 26–36, 2007.Link | ISI | Google Scholar6 Charmot-Bensimon D. Human globin genes: what can we learn from their polymorphism? Bull Soc Pathol Exot 92: 242–248, 1999.ISI | Google Scholar7 Diggs LW, Flowers E. High school athletes with the sickle cell trait (Hb A/S). J Nat Med Assoc 68: 492–493, 1976.Google Scholar8 Francis CK, Bleakley DW. The risk of sudden death in sickle cell trait: noninvasive assessment of cardiac responses to exercise. Catheter Cardiovasc Diag 6: 73–80, 1980.Crossref | Google Scholar9 Freund H, Lonsdorfer J, Oyono-Enguéllé S, Lonsdorfer A, Dah C, Bogui P. Lactate exchange and removal abilities in sickle cell trait carriers during and after incremental exercise. Int J Sports Med 16: 428–434, 1995.Crossref | PubMed | ISI | Google Scholar10 Gima AS, Bemis EL. Absence of major illnesses in sickle cell trait: results from a controlled study. J Nat Med Assoc 67: 216–219, 1975.Google Scholar11 Gozal D, Thiriet P, Mbala E, Wouassi D, Gelas H, Geyssant A, Lacour JR. Effect of different modalities of exercise and recovery on exercise performance in subjects with sickle cell trait. Med Sci Sports Exerc 24: 1325–1331, 1992.Crossref | PubMed | ISI | Google Scholar12 Kramer MS, Pearson HA. Growth and development in children with sickle cell trait. A prospective study of matched pairs. N Engl J Med 299: 686–689, 1978.Crossref | ISI | Google Scholar13 Le Gallais D, Lonsdorfer J, Fabritius H, Bogui P, Sangaré A, Cabannes R. Prevalence of the sickle cell trait among students in a physical education college in Côte d'Ivoire. Nouv Rev Fr Hematol 31: 409–412, 1989.Google Scholar14 Le Gallais D, Préfaut C, Dulat C, Macabies J, Lonsdorfer J. Sickle cell trait in Ivory Coast athletic champions. Int J Sports Med 12: 509–510, 1991.Crossref | ISI | Google Scholar15 Le Gallais D, Préfaut C, Mercier J, Bilé A, Bogui P, Lonsdorfer J. Sickle cell trait as a limiting factor for high-level performance in a semi-marathon. Int J Sports Med 15: 399–402, 1994.Crossref | ISI | Google Scholar16 Murphy JR. Sickle cell hemoglobin (Hb AS) in black football players. JAMA 225: 981–982, 1973.Crossref | ISI | Google Scholar17 Pearson HA. Sickle cell trait and competitive athletics: is there a risk? Pediatrics 83: 613–614, 1989.ISI | Google Scholar18 Robinson JR, Stone WJ, Asendorf AC. Exercise capacity of black sickle cell trait males. Med Sci Sports 8: 244–245, 1976.Google Scholar19 Sara F, Hardy-Dessources MD, Marlin L, Connes P, Hue O. Lactate distribution in the blood compartments of sickle cell trait carriers during incremental exercise and recovery. Int J Sports Med 27: 436–443, 2006.Crossref | ISI | Google Scholar20 Scoville SL, Gardner JW, Magill AJ, Potter RN, Kark JA. Nontraumatic deaths during US armed forces basic training, 1977–2001. Am J Prev Med 26: 205–212, 2004.Crossref | ISI | Google Scholar21 Stark AD, Janerich DT, Jereb SK. The incidence and causes of death in a follow-up study of individuals with haemoglobin AS and AA. Int J Epidemiol 9: 325–328, 1980.Crossref | ISI | Google Scholar22 Steingberg MH, Embury SH. Alpha-thalassemia in Blacks: genetic and clinical aspects and interactions with the sickle hemoglobin gene. Blood 68: 985–990, 1986.Crossref | PubMed | ISI | Google Scholar23 Storey KB. Gene hunting in hypoxia and exercise. Adv Exp Med Biol 588: 293–309, 2006.Crossref | PubMed | ISI | Google Scholar24 Thiriet P, Lobe MM, Gweha I, Gozal D. Prevalence of the sickle cell trait in an athletic West African population. Med Sci Sports Exerc 23: 389–390, 1991.ISI | Google Scholar25 Thiriet P, Wouassi D, Bitanga E, Lacour JR, Gozal D. Hyperoxia during recovery from consecutive anaerobic exercises in the sickle cell trait. Eur J Appl Physiol 71: 253–258, 1995.Crossref | ISI | Google Scholar26 Thiriet P, Le Hesran JY, Wouassi D, Bitanga E, Gozal D, Louis FJ. Sickle cell trait performance in a prolonged race at high altitude. Med Sci Sports Exerc 26: 914–918, 1994.Crossref | ISI | Google Scholar27 Weisman IM, Zeballos RJ, Johnson BD. Cardiopulmonary and gas exchange responses to acute strenuous exercise at 1,270 meters in sickle cell trait. Am J Med 84: 377–383, 1988.Crossref | ISI | Google Scholar28 Weisman IM, Zeballos RJ, Johnson BD. Effect of moderate inspiratory hypoxia on exercise performance in sickle cell trait. Am J Med 84: 1033–1040, 1988.Crossref | ISI | Google Scholar29 Weisman IM, Zeballos RJ, Martin TW, Johnson BD. Effect of army basic training in sickle cell trait. Arch Intern Med 148: 1140–1144, 1988.Crossref | Google Scholar30 Wittwer M, Billeter R, Hoppeler H, Flück M. Regulatory gene expression in skeletal muscle of highly endurance-trained humans. Acta Physiol Scand 180: 217–227, 2004.Crossref | PubMed | Google Scholar Download PDF Previous Back to Top Next FiguresReferencesRelatedInformation Cited ByMicrofluidic concurrent assessment of red blood cell adhesion and microcapillary occlusion: potential hemorheological biomarkers in sickle cell disease1 January 2023 | Sensors & Diagnostics, Vol. 2, No. 2Lower Muscle and Blood Lactate Accumulation in Sickle Cell Trait Carriers in Response to Short High-Intensity Exercise24 January 2022 | Nutrients, Vol. 14, No. 3Does physical activity increase or decrease the risk of sickle cell disease complications?23 December 2015 | British Journal of Sports Medicine, Vol. 52, No. 4Impact du trait drépanocytaire sur la rigidité artérielle des sujets africainsJMV-Journal de Médecine Vasculaire, Vol. 42, No. 1Transgenic sickle cell trait mice do not exhibit abnormal thermoregulatory and stress responses to heat shock exposureBlood Cells, Molecules, and Diseases, Vol. 59Role of Exercise-Induced Oxidative Stress in Sickle Cell Trait and Disease14 December 2015 | Sports Medicine, Vol. 46, No. 5Blood viscosity is lower in trained than in sedentary sickle cell trait carriersClinical Hemorheology and Microcirculation, Vol. 61, No. 1Actor network theory, agency and racism: The case of sickle cell trait and US athletics28 January 2015 | Social Theory & Health, Vol. 13, No. 1National Athletic Trainers' Association Position Statement: Preparticipation Physical Examinations and Disqualifying ConditionsJournal of Athletic Training, Vol. 49, No. 1Évaluation de la déformabilité érythrocytaire des sujets porteurs de trait drépanocytaire au cours d’un match de football : effet de l’hydratation ad libitum20 March 2013 | Bulletin de la Société de pathologie exotique, Vol. 106, No. 2Effects of regular physical activity on skeletal muscle structural, energetic, and microvascular properties in carriers of sickle cell traitLucile Vincent, Samuel Oyono-Enguéllé, Léonard Féasson, Viviane Banimbek, Macias Dohbobga, Cyril Martin, Patrice Thiriet, Alain Francina, Hervé Dubouchaud, Hervé Sanchez, Rachel Chapot, Christian Denis, André Geyssant, and Laurent Messonnier15 August 2012 | Journal of Applied Physiology, Vol. 113, No. 4Exercise training blunts oxidative stress in sickle cell trait carriersErica N. Chirico, Cyril Martin, Camille Faës, Léonard Féasson, Samuel Oyono-Enguéllé, Emeline Aufradet, Hervé Dubouchaud, Alain Francina, Emmanuelle Canet-Soulas, Patrice Thiriet, Laurent Messonnier*, and Vincent Pialoux*1 May 2012 | Journal of Applied Physiology, Vol. 112, No. 9Screening U.S. College Athletes for Their Sickle Cell Disease Carrier StatusAmerican Journal of Preventive Medicine, Vol. 41, No. 6Testing of Collegiate Athletes for Sickle Cell Trait: What We, as Genetic Counselors Should Know19 April 2011 | Journal of Genetic Counseling, Vol. 20, No. 4Survey of Sickle Cell Trait Screening in NCAA and NAIA Institutions13 March 2015 | The Physician and Sportsmedicine, Vol. 39, No. 1Effects of hydration and dehydration on blood rheology in sickle cell trait carriers during exerciseJulien Tripette, Gylna Loko, Abdoulaye Samb, Bertin Doubi Gogh, Estelle Sewade, Djibril Seck, Olivier Hue, Marc Romana, Saliou Diop, Mor Diaw, Karine Brudey, Pascal Bogui, Fallou Cissé, Marie-Dominique Hardy-Dessources, and Philippe Connes1 September 2010 | American Journal of Physiology-Heart and Circulatory Physiology, Vol. 299, No. 3A medical consideration for sickle cell trait carriers in sports: example of GuadeloupeScandinavian Journal of Medicine & Science in Sports, Vol. 19, No. 4Comment on Point:Counterpoint: Sickle cell trait should/should not be considered asymptomatic and as a benign condition during physical activityDaniel Le Gallais1 January 2009 | Journal of Applied Physiology, Vol. 106, No. 1Sickle cell trait should/should not be considered asymptomatic and as a benign condition during physical activityJohn H. Boucher1 April 2008 | Journal of Applied Physiology, Vol. 104, No. 4Physiological Responses of Sickle Cell Trait Carriers during ExerciseSports Medicine, Vol. 38, No. 11Sickle cell trait should be considered asymptomatic and as a benign condition during physical activityOguz K. Baskurt, and Herbert J. Meiselman1 December 2007 | Journal of Applied Physiology, Vol. 103, No. 6 More from this issue > Volume 103Issue 6December 2007Pages 2137-2138 Copyright & PermissionsCopyright © 2007 the American Physiological Societyhttps://doi.org/10.1152/japplphysiol.00338.2007PubMed17395764History Published online 1 December 2007 Published in print 1 December 2007 Metrics