A Case for Iron Deficiency as a Marker of Inequality in Care Access and Treatment

Iron deficiency and its role in equitable health care.

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Iron deficiency represents more than a medical condition; it is a reflection of persistent health disparities, according to an editorial published in The Lancet Haematology.¹ Tackling this global challenge requires a multifaceted approach that prioritizes equity, addresses underlying causes, and improves access to care. With continued momentum, the article stated the burden of iron deficiency can be reduced, enhancing the quality of life for millions worldwide.

Non-anemic iron deficiency is a common yet often overlooked condition that predominantly affects women, girls, and individuals in low- and middle-income countries (LMICs). While anemia impacts nearly a quarter of the world's population, the prevalence of iron deficiency may be twice as high, highlighting the severity of this public health concern.

Diagnosis and Treatment Challenges

Iron deficiency often goes undiagnosed or inadequately treated due to challenges in defining and managing the condition. A recent study published in Blood Advances analyzed data from 13,084 patients in the United States with laboratory-confirmed iron deficiency.² It was found that 58% of patients did not resolve their deficiency within 3 years of diagnosis, even with repeated ferritin testing. For those who did see improvement, the median time to resolution was nearly 2 years.

Understanding the effects of iron deficiency separate from anemia can be complex.¹ However, those with iron deficiency often experience symptoms like fatigue, weakness, intolerance to exercise, and cognitive difficulties. The implications are even more significant for pregnant individuals, as iron deficiency has been associated with adverse neurodevelopmental outcomes in infants.

The quality-of-life impact is significant, yet historical diagnostic practices often fail to capture the condition. Current evidence suggests that a ferritin level of 30 µg/L or less is sensitive and specific for diagnosing absolute iron deficiency. However, some experts advocate using a threshold of 50 µg/L to better identify affected individuals, the article acknowledged. Functional iron deficiency, marked by an inability to utilize stored iron due to underlying inflammatory conditions such as chronic kidney disease, requires different diagnostic approaches, including measuring transferrin saturation.

Disproportionate Burden and Barriers to Treatment

Recent data highlight significant disparities in the prevalence of iron deficiency. A study conducted in September 2024 estimated that 14% of adults in the US experience absolute iron deficiency, while 15% are affected by functional iron deficiency. Among women aged 18 to 50 years, the prevalence of absolute iron deficiency is particularly concerning, reaching 34% (95% CI, 31-37), whereas functional iron deficiency is more commonly observed in older women and men across all age groups.

Factors such as menstruation and pregnancy place women and girls at a higher risk for absolute iron deficiency, specifically when factoring in the under-detected possibility of rare blood disorders like hemophilia.³

A discrepancy exists in how treatments for hemophilia are tested in clinical trials, primarily focusing on men. This can limit the scope of treatments for women who generally have higher hormone levels, Margaret Ragni, MD, MPH, professor of medicine and clinical and translational research in the Division of Hematology/Oncology at the University of Pittsburgh, director of the Hemophilia Center of Western Pennsylvania, and American Society of Hematology expert, explained in an interview with The American Journal of Managed Care^® (AJMC^®) Center on Health Equity & Access.

Treatment options for iron deficiency include oral iron supplements and intravenous iron therapy.¹ Oral iron is generally cost-effective; however, gastrointestinal adverse effects can limit its use for some patients. Alternatively, intravenous iron is safe and effective but may be difficult to access due to logistical or financial barriers.

Functional iron deficiency typically requires treatment of the underlying inflammatory condition, adding another layer of complexity to its management. In LMICs, additional challenges exacerbate the issue. Food insecurity, untreated heavy menstrual bleeding, and increasing inflammatory conditions, such as obesity, contribute to the prevalence of iron deficiency. This condition often reflects broader health inequities and serves as an indicator of unmet nutritional and health care needs.

Iron Deficiency: A Marker of Inequality

Increased research has highlighted the widespread issue of iron deficiency, especially among women, and the difficulties in diagnosing and treating it. This increasing awareness should now lead to significant changes in health care to enable timely and effective diagnosis and management.

"Iron deficiency itself can serve as a marker of inequality and unmet health needs since it emerges when nutrition is not optimal or when a related condition or disease is not being adequately managed," the article stated. "Numerous barriers to the recognition of non-[anemic] iron deficiency as a substantial health burden still exist."

The need for improved diagnostic criteria, such as raising ferritin cutoff levels and incorporating measures for functional iron deficiency, was further emphasized. Equally important is the need to expand access to treatments, particularly intravenous iron, and to address the underlying causes of insufficient iron intake, absorption, and utilization.

References

1. The Lancet Haematology. Iron deficiency as a marker of inequality. Lancet Haematol. 2024;11(11):e803. doi:10.1016/S2352-3026(24)00318-1

2. Cogan J, Meyer J, Jiang Z, Sholzberg M. Iron deficiency resolution and time to resolution in an American health system. Blood Adv. 2024; bloodadvances.2024013197. doi:10.1182/bloodadvances.2024013197

3. Grossi G. Breaking barriers in bleeding disorders: experts call for more data on women. Am J Accountable Care. 2024;12(1):38-40. doi:10.37765/ajac.2024.89525