The Hidden Toll of Iron Deficiency: Beyond Anemia

If you find yourself feeling tired or prone to illness, it could be an indication that you are low on your iron stores. Symptoms associated with iron deficiency, like general fatigue or headaches, are often brushed off without low hemoglobin, especially when the concerns are raised by patients who are women. Iron deficiency without anemia (IDWA) is widespread, yet often ignored, even though its impacts can be particularly profound.

Understanding Iron Deficiency

Iron is crucial for the production of hemoglobin, the protein in red blood cells that carries oxygen throughout the body. When iron levels are low, the body struggles to maintain optimal hemoglobin levels, but it may not yet reach the medical threshold for anemia. Though Iron Deficiency and Iron Deficiency Anemia are often used interchangeably, there is a key differentiator: ID refers to insufficient iron stores that do not meet the body's needs, regardless of anemia. 

The Underreported Reality

Iron deficiency without anemia is frequently underreported because it doesn’t always present with the dramatic symptoms associated with anemia, such as fatigue and weakness. However, the subtle impacts can be just as significant. Symptoms might include general fatigue, reduced cognitive function, and a compromised immune system, which can severely impact daily life. This highlights the importance of recognizing IDWA as a distinct clinical condition, particularly in patients with chronic conditions like heart failure, where IDWA can adversely affect long-term outcomes.

Globally, iron deficiency anemia is estimated to impact 1.2 billion people, and iron deficiency without anemia (IDWA) is estimated to impact at least twice as many. A study in the US between 2003 and 2020 found that among females aged 12-21, iron deficiency affected nearly 40% while iron deficiency anemia affected 6%. This statistic highlights the broader scope of the problem and the need for increased awareness and intervention within our healthcare systems and global health programming.  

Impact on Women's Health

For women, the stakes are particularly high, with the impacts far-reaching. Iron deficiency can have effects on reproductive health and overall well-being; impacts that are too often ignored or normalized. Menstruation and pregnancy create additional biological needs for more iron. Without treatment, low iron can lead to persistent deficiencies or pregnancy complications, including postpartum hemorrhage and impacts on fetal development. This can lead to long-term health issues for the child. 

Low iron can also impact mental health, affecting mood and cognitive function. Finally, chronic iron deficiency can lead to reduced productivity and absenteeism at work. Iron deficiency is correlated with a 20-25% decrease in work productivity, impacting an individual’s ability to work effectively and their earning potential.

The Dismissal of Iron Deficiency

Despite these impacts, iron deficiency without anemia is often dismissed as less critical. This oversight can lead to insufficient screening and treatment, leaving many women struggling with their symptoms without a clear path forward. The focus on anemia as the primary indicator of iron deficiency means that many individuals with milder forms do not receive the support and interventions they need. Additionally, addressing iron deficiency before it becomes anemia should be a priority.

Many advocates and health researchers around the world have been advocating for greater acknowledgement of IDWA. On September 9th, 2024, new Ontario guidelines redefined how ID is diagnosed, meaning those who were previously told their iron levels were normal could finally get the treatment and support they need. In the past, adults needed to have ferritin levels as low as 1-15 ug/l before being flagged for intervention. 

Now, the threshold has increased to 30 ug/L. Dr. Michelle Sholzberg, Director of Hematology at the University of Toronto, advocated for this change for years along with many other industry stakeholders. “We want to see this problem addressed earlier because it’s totally correctable, which means the problem is unnecessary,” Scholzberg said. “It’s a structural problem and we’re structurally solving it.” 

We are encouraged to see the growing awareness of the need to recognize IDWA as a distinct clinical challenge. Further work is needed to increase awareness among the general population and the health care community. This will require adequate nutrition training about iron-rich foods and other tools like supplementation and fortification, which can help address iron deficiency. For healthier populations everywhere, IDWA needs to be treated when identified, rather than waiting for it to turn into anemia.