Iron deficiency in women: assessment, causes and consequences

Jane Coada and Cathryn Conlonb

a
Institute of Food, Nutrition and Human Health,
Massey University, Palmerston North and bInstitute of
Food, Nutrition and Human Health, Massey University,
Albany, Auckland, New Zealand
Correspondence to Jane Coad, PhD, Institute of Food,
Nutrition and Human Health, Massey University,
Palmerston North 4442, New Zealand
Tel: +64 6350 5962; e-mail: j.coad@massey.ac.nz
Current Opinion in Clinical Nutrition and
Metabolic Care 2011, 14:625–634
Purpose of review
Iron deficiency is the most common nutritional disorder affecting about 20–25% of the
world’s population, predominantly children and women. There is emerging evidence that
depletion of iron stores may have adverse consequences for adults even in the absence
of anaemia. This raises issues about the most appropriate method of assessing iron
status.
Recent findings
Although the effects of iron-deficiency anaemia are well characterized, emerging
evidence suggests that iron deficiency without anaemia can have negative
consequences in adults, particularly for neurocognitive outcomes. Iron deficiency is
more likely in women of reproductive age because of menstrual blood loss. However,
extremes of blood loss such as regular blood donation, diets of low bioavailability and
the challenges of pregnancy all markedly increase the risk of iron deficiency. In addition,
the physiological changes in pregnancy affect the normal reference ranges used in
laboratory assessment. The use of haemoglobin as a marker of iron deficiency is limited
by its low specificity and sensitivity and although the use of alternative biomarkers is
becoming more common, interpreting results in conditions of chronic inflammation,
including that associated with increased adiposity, needs more investigation.
Summary
By understanding the physiology of iron metabolism alongside the limitations and
interpretation of biomarkers of iron deficiency, clinicians and nutritionists are better
equipped to identify changes in iron balance and to further investigate the functional
outcomes of iron deficiency.

Keywords
biomarkers, iron deficiency, iron metabolism, risk factors

Curr Opin Clin Nutr Metab Care 14:625–634

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1363-1950

are reduced. Presentation of clinical symptoms is

Introduction
Iron deficiency continues to be the most common nutri-
tional disorder and public health problem in the world
[1,2], affecting about 20–25% of the world population,
disproportionately children and women. Iron deficiency
is traditionally categorized into stages [3] (see Table 1):
(1) mild deficiency or iron depletion characterized by
depleted stores with normal production of haemo-
globin (Hb) and iron-dependent proteins;
(2) marginal deficiency or iron-deficient erythropoiesis
characterized by depleted iron stores, decreased
iron-dependent protein production but normal Hb
concentrations; and
(3) iron-deficiency anaemia (IDA), defined as a
decreased concentration of circulating red blood cells
(RBCs) or decreased concentration of Hb within
blood cells, resulting in compromised transport of
oxygen to tissues; iron stores are depleted and the
concentrations of iron-dependent oxidative enzymes
variable depending on the rapidity of development;
slower progression allows more effective physiologi-
cal adaptation.
Although iron deficiency is the major cause of anaemia,
not all anaemia is IDA. Other forms of anaemia result
from other nutrient deficiencies (such as vitamin B12,
folate and vitamin A), acute and chronic inflammation,
parasitic infections and disorders that affect Hb synthesis
or RBC production or survival (such as haemoglobino-
pathies).
Women, particularly those of reproductive age, are at
much higher risk of iron deficiency. This has implications
for not only their health but also that of their offspring.
In addition to its role in the synthesis of Hb, iron has a
number of roles in tissue. Emerging evidence suggests
that iron deficiency without anaemia (IDWA) may be
associated with symptoms which result from impaired
cellular metabolism. Although the measurement of Hb

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 626 Micronutrients

concentration has both low sensitivity and low specificity,
Hb concentration is commonly used as the biomarker
to determine the prevalence of iron deficiency despite
changes in Hb being a relatively late consequence of
iron deficiency. In order to both determine the effects
of preanaemic iron deficiency and identify women at
increased risk, it is important to consider the strengths
and limitations of alternative methods of assessing iron
status.
Physiology of iron metabolism related to
assessment of iron deficiency
Identification of the most appropriate biomarker for
determining iron status is determined by the physiologi-
cal responses to adequate and inadequate iron supplied to
various tissues.
Dietary iron
Iron is present in food as haem iron and as nonhaem iron.
Haem iron, from proteolytic digestion of Hb and
myoglobin, is absorbed efficiently (about 40%), whereas
absorption of nonhaem iron is less efficient and strongly
influenced by other dietary components [4

]. In
addition, ferritin from plant (particularly legume) and
animal food sources and lactoferrin from milk contribute
to dietary iron [4

]. Absorption of dietary iron depends
primarily on the physiological status of the individual
(iron-deplete individuals absorb more iron) and on its
bioavailability in the diet (higher in diets rich in meat and
ascorbic acid). Iron is unusual in that selective absorption
of dietary iron is the primary homeostatic mechanism
involved in regulating iron balance.
Absorption
Dietary nonhaem iron is predominantly in the insoluble
ferric form (Fe3þ) bound to components of food. Follow-
ing digestion, uptake of nonhaem iron requires reduction
to ferrous (Fe2þ) iron by ferrireductases such as duodenal
cytochrome B (dcytB) [5] or by dietary ascorbic acid.
Subsequent transport across the apical membrane of the
Key points

Changes in Hb concentration are not specific or
sensitive in determining iron deficiency.

Iron deficiency without anaemia may compromise
neurocognitive outcomes.

Dietary forms of iron include ferritin as well as the
better characterized haem and nonhaem iron.

Iron status and iron requirements in women of
reproductive age are significantly affected by men-
strual blood loss and can be further compromised by
other causes of blood loss including blood donation.

Laboratory assessment of iron status is complicated
by the normal physiological changes in pregnancy.

Chronic inflammation, which is common in hospi-
talized patients, the elderly and in obese indi-
viduals, may affect body sequestration of iron and
iron absorption making biomarkers of iron status
difficult to interpret.
proximal duodenum enterocytes via the divalent metal
transporter 1 (DMT1) is a process that requires proton co-
transport (see [6

] for recent review of mechanisms
involved in iron metabolism). Absorption of nonhaem
iron is inhibited by phytic acid (in cereals and legumes)
and by polyphenols (in coffee, tea, wine and some
vegetables) (see [4

] for a comprehensive review of
dietary factors affecting iron absorption and the mech-
anisms involved). Enhancers of nonhaem iron absorption
include ascorbic acid, citric acid and some other organic
acids, carotenes, alcohol and a yet-to-be-identified factor
in meat, poultry and fish.
Dietary haem is transported into the enterocyte by less-
well characterized mechanisms, probably via a haem
carrier protein [7] followed by subsequent internalization
in cytoplasmic vesicles from which Fe2þ is liberated by
haemoxygenase 1.
Ferritin, the ubiquitous and highly conserved iron storage
molecule derived from both plant and animal foods which
is relatively resistant to proteolytic digestion, is probably

Table 1 Sequential stages of iron deficiency in women

Early negative Depletion of Iron-deficient
Normal iron balance storage iron erythropoiesis Iron-deficiency anaemia

Bone marrow iron 2–3 1 0–1 0 0

Score [1–3,4

,5,6

]
Erythrocytes Normal Normal Normal Normal Microcytic and hypochromic
Hb (g/l) 120–160 120–160 120–160 120–160 <120
Erythrocyte protoporphyrin (mg/dl) 30 30 30 <15 <15
Plasma iron (mg/dl) 115 þ 15 <120 115 <60 <40
TIBC(mg/dl) 330  30 330–360 360 390 410
Ferritin (mg/l) 100  60 <25 20 10 <10
Soluble transferrin receptors Normal Normal–high High Very high Very high
Transferrin saturation (%) 35  15 30 30 <15 <15
Iron absorption (%) 5–10 10–15 10–15 10–20 10–20
Adapted with permission from [3]. Hb, haemoglobin; TIBC, total iron-binding capacity.

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taken up by the enterocyte by an independent mech-
anism probably mediated by a high-affinity receptor
followed by endocytosis [8,9].
In the enterocyte, Fe2þ from all dietary sources enters a
common labile iron pool within the cytosol from which it
may be used for cellular metabolism, sequestered within
the enterocyte as ferritin, where it may be retained until
the enterocyte is sloughed off into the lumen of the gut,
or exported into the bloodstream. Fe2þ is exported via
the Fe2þ transporter, ferroportin [6

], on the basolateral
membrane and subsequently oxidized to Fe3þ by
hephaestin, a membrane-bound ferroxidase [10].
Ferroportin is involved in the efflux of iron into the
blood-stream from both enterocytes and macrophages,
release of iron from other tissues into the bloodstream and
placental transfer of iron to the fetus. The ferroportin-
mediated egress of Fe2þ is negatively regulated by the
hepatic peptide, hepcidin, which binds to ferroportin
resulting in its internalization and subsequent degradation.
Hepcidin also inhibits the expression of DMT1 [11] and
dcytB on the apical membrane of the enterocyte, thus
abrogating iron uptake into the cell. Hepcidin levels
decrease in IDA, hypoxia and oxidative stress [12], so
intestinal iron absorption, release of recycled iron from
macrophages and mobilization of stored iron from
hepatocytes are all increased [13]. Hepcidin levels
increase in response to inflammatory cytokines and infec-
tion [14]; the increased hepcidin in response to infection
is important in depriving pathogens of essential iron
which inhibits their proliferation [15

]. Conditions of
systemic iron overload result from a lack of control by
hepcidin of the ferroportin-mediated export of iron;
excessively high hepcidin levels are responsible for the
anaemias associated with chronic diseases, inflammation,
cancer and ageing.
Transport
Iron exported from the enterocyte is transported to
all tissues as diferric transferrin (Tf); transferrin also
scavenges iron recycled from effete red cells by reti-
culoendothelial cells. Plasma Tf has a high-binding
capacity and under normal physiological conditions, is
hyposaturated (about 25–50%) and in excess of iron
concentration so there is a negligible amount of circulat-
ing, nontransferrin-bound iron which has a high redox
activity and is potentially toxic [16]. In iron deficiency,
Tf saturation may fall below 5% [17]; at Tf saturation less
than 15%, delivery of iron to the bone marrow is unable to
sustain normal rates of erythropoiesis, so Tf saturation is a
key factor for establishing iron deficiency [18].
Cells express specific transferrin receptors (TfRs);
the ligand–receptor complex is taken up by endocytosis.
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Iron deficiency in women Coad and Conlon 627
A proton pump results in acidification of the endocytic
vesicle reducing the affinity of transferrin for iron, so it is
released into the cytosol [6

]. The density of transferrin
receptors on the cell surface reflects cell requirements;
increased iron requirement (or iron deprivation) upregu-
lates synthesis of transferrin receptors (their expression is
particularly high on dividing cells such as RBC precursors
and placenta) [19]. A monomeric fragment is cleaved
off from the transferrin receptor resulting in very low
concentrations of soluble transferrin receptors (sTfRs) in
the serum; receptor number correlates well with the
number of erythroid precursors [20], thus measurement
of sTfR indicates iron demand versus supply.
Storage
Iron is stored largely in the reticuloendothelial cells of
the liver, the spleen and bone marrow as ferritin which is
a protein shell (apo-ferritin) made up of 24 heavy and
light subunits, involved in both iron storage and iron
detoxification. Up to 4500 Fe3þ ions are deposited in the
core of apo-ferritin as insoluble ferric hydroxide phos-
phate forming holo-ferritin. Iron reserves act to buffer
increased physiological demands for iron such as in
pregnancy and with acute blood loss. Minute quantities
of the light subunit of ferritin (free of iron) are present in
serum; serum ferritin levels correlate well with storage
iron which varies with age and sex. In women who are not
pregnant or lactating, a serum ferritin concentration of
1 mg/l is equivalent to about 7–8 mg mobilizable iron, so a
serum ferritin concentration of 50 mg/l indicates that iron
stores are adequate (350–400 mg) for normal needs [21].
Combinations of biomarkers are valuable; the sTfR :
serum ferritin (R : F) ratio is a particularly useful marker
of iron status which has been applied to population studies
[22

]; it gives a continuum across the sequential stages of
iron deficiency. In addition, the sTfR : serum ferritin ratio
has been validated against serial phlebotomy to determine
a quantitative measure of body iron stores or tissue iron
deficiency [20].
Several biomarkers, including serum iron, serum ferritin
and transferrin saturation, used to assess iron status are
acute-phase reactants to inflammatory cytokines (which
are increased with a range of conditions including
infection, inflammation, liver disease, hyperthyroidism,
malignancy, alcohol consumption, obesity and use of oral
contraceptives). This means that inflammatory states are
associated with increased risk of iron deficiency and it is
important to concurrently assess biomarkers of iron status
with acute phase protein biomarkers such as C-reactive
protein (CRP) and/or a1-acid glycoprotein (AGP). Inter-
pretation of test results presents some challenges; either
individuals with inflammation can be excluded from
analysis of data or the cut-off definition of low ferritin
concentration is increased, for example, from 12–15 to
 628 Micronutrients
30–50 mg/l [23]. It is argued that measuring both CRP
and AGP presents the optimal picture of inflammatory
time-course: CRP rises rapidly, peaking between 24 and
48 h, whereas AGP increases over 4–5 days [24
]; cut-off
levels for confirming inflammation are greater than 5 mg/l
and greater than 1 g/l, respectively.
With the increasing prevalence of overweight and obesity
worldwide, use of biomarkers of iron status which can be
affected by inflammatory cytokines is challenging.
It seems that increased body adipose tissue, particularly
visceral depots, is associated with increased risk of iron
deficiency which may be masked by high serum ferritin
levels [25], presumably because the cytokines increase
hepcidin synthesis resulting in increased macrophage
sequestration and/or decreased intestinal iron absorption
[26
].
Utilization
Erythropoiesis is driven by erythropoietin and limited
by nutrient availability. Transferrin delivers most of
the circulating iron to the erythropoietic precursors in
the bone marrow. Erythropoiesis takes about 7 days. The
final stage is the release of reticulocytes which circulate in
the bloodstream for about a day before they mature into
erythrocytes; reticulocytes can be identified because they
are larger than RBC, contain remnants of nuclei and have
a high surface concentration of TfR which are shed as
the erythrocytes mature [18]. Usually reticulocyte
number comprises 1% of the total RBCs (50 000/ml of
blood); increased reticulocyte number reflects increased
erythropoiesis [18]. Iron deficiency is associated with
increased release of reticulocytes which are larger
and paler than normal. Indices such as reticulocyte size
(Ret-Y) and Hb content (ChR) are useful markers of
functional iron deficiency [27].
The final step in Hb formation is the combination
of ferrous protoporphyrin (haem) and globin. Usually,
zinc protoporphyrin is produced in trace amounts during
haem synthesis; but in iron deficiency, zinc ions replace
some of the ferrous ions in the last stages of erythropoiesis
so more zinc protoporphyrin (ZPP) is formed and
incorporated into red cells [28]. Iron deficiency results
in compromised Hb synthesis and microcytosis; small,
hypochromic and abnormally shaped cells are evident
on a blood smear [29]. Although abnormalities in cell
morphology, which can be detected by automated cell
counters, are useful in differential diagnosis of the causes
of anaemia, the slow turnover of RBCs means that these
are only detected when iron deficiency has been present
for months. Erythrocytes contain 80% of the body’s
functional iron and have a lifespan of about 90–120 days,
so about 1% of erythrocytes are replaced each day.
Kupffer cells in the liver and other macrophages predo-
minantly in the spleen recognize the membrane changes
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of the effete erythrocytes and phagocytose them.
The iron from the erythrocytes is then retained inside
the macrophages which act as an iron store until the iron is
transported out of the cells by ferroportin. Iron liberated
and recycled from senescent red cells contributes about
20–25 mg of iron each day which is about 90% of that
required for erythropoiesis, the remainder comes from
the diet.
Although most of the body iron (about 40 mg/kg body
weight) is present in erythrocytes and myoglobin, iron has
a myriad of other functions which derive from the ability
of iron to donate electrons. A small proportion of body
iron is an essential component of the metalloenzymes
involved in the formation of ATP and DNA synthesis.
In addition, cellular proliferation requires iron; dividing
cells, such as erythrocyte precursors and immune cells,
have increased expression of TfR. Iron is used by
neutrophils and macrophages to generate the cytotoxic
free radical oxygen burst.
Iron concentrations in the brain are abundant with an
unusual and distinctive pattern of distribution [30] that
probably reflects differences in cell division, myelination,
metabolism and neurotransmission. Iron uptake by the
brain is regulated by the expression of transferrin recep-
tors on the endothelial cells of the brain microvasculature
[31]. How iron is redistributed within the brain is not well
understood, but iron continues to accumulate in humans
until the fourth decade of life and then plateaus [32].
The amount of iron accumulated exceeds the amount
calculated to be required by the iron-dependent
processes by about 10-fold [33]; it is not clear what its
role is but inappropriate accumulation, either excess or
mislocalization, of iron with age is associated with
neurodegenerative and movement disorders, including
Alzheimer and Parkinson’s diseases [30], age-related
macular degeneration and restless legs syndrome [34].
The mechanism involved is probably iron-catalyzed
oxidative stress, particularly affecting mitochondria
[35]; indeed, recent studies in mouse models suggest
that iron chelation therapy, even in the absence of iron
deregulation, may have neuroprotective potential [36].
Animal studies suggest that although the developing
brain is vulnerable to iron deficiency [37], the adult brain
conserves iron moderately well even in the presence of
iron deficiency, although severe iron deficiency can cause
changes in brain fatty acid profile because iron is a
component of the fatty acid desaturase enzymes [38].
Pregnancy
Pregnancy is marked by significant changes in the
haematological system [39]: the increased plasma volume
is greater than the increased production of cellular

components, so hypovolaemia causes progressive
changes in many of the common haematological labora-
tory values [40] (see Table 2). Blood volume increases
by 30–40% (about 1.5 l; more with multiple gestation)
from 6 to 8 weeks, peaking at 28–34 weeks; increased
RBC number lags slightly behind. The expansion
of plasma volume is positively associated with the
outcome of pregnancy; lack of haemodilution is usually
because of preeclampsia [39]. However, true com-
promised iron status in pregnancy is associated with
adverse outcomes.
There is a physiological increase in inflammatory
biomarkers in pregnancy, particularly in the first and
third trimesters [43], so the cut off for serum ferritin in
pregnancy is higher than for nonpregnant women but
serum ferritin levels can markedly increase as a result of
cellular damage associated with preeclampsia [44].
Causes of iron deficiency
Iron deficiency is due to increased requirement, such as
growth or pregnancy, increased blood loss and/or low
dietary intake of iron. Although iron balance is main-
tained by iron acquisition, the ability of the body to
increase iron uptake across the gastrointestinal tract is
finite. Worldwide, the most significant factors influencing
iron deficiency are increased blood loss due to parasitic
infection and limited dietary diversity due to poverty and
low bioavailability of iron from a diet high in plants foods
and low in animal-derived foods [45

]. In developed
countries where the burden of infection is less, the usual
causes of iron deficiency in premenopausal nonpregnant
women are a low intake of dietary iron, menstrual losses
and blood donation. Vegetarian diets have lower bio-
availability of iron, so vegetarian women of reproductive
age are recommended to increase their iron intake by
1.8-fold [46] from 18 to 32 mg/day.
Iron deficiency develops when absorption of dietary
iron cannot match the obligate losses, which are predo-
minantly from desquamated skin (0.3 mg per day) and
gastrointestinal cells (0.6 mg per day) plus small
amounts in sweat and urine (0.1 mg per day), that in
total account for approximately 1 mg iron/day, and
variable blood loss. The average menstrual blood loss
is 35 ml per cycle, with a range of 25–60 ml [39]. It is
lower in women using oral contraception and higher in
women using intrauterine contraceptive devices [47] and
can be in excess of 250 ml (average 60 ml) in women
of late reproductive age [48]. A blood loss of 35 ml per
28-day cycle equates to a loss of 0.5–0.68 mg iron per day
in addition to other obligate iron losses. The usual blood
donation unit of about 450 ml equates to an additional
loss of 1–1.35 mg per day, assuming 6 months between
blood donations. Other sources of blood loss such as
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Iron deficiency in women Coad and Conlon 629
nosebleeds and foot-strike-haemolysis in athletes can
also have an impact on iron balance.
Pregnancy presents a significant physiological challenge
to iron balance. The iron cost of pregnancy is about 1.2 g,
comprising approximately 270 mg in the fetus, approxi-
mately 90 mg in the placenta, approximately 450 mg
in maternal erythrocyte expansion and approximately
230 mg total basal losses [49

]. Although approximately
600 mg can be recovered from cessation of menses and
recovery of the erythrocyte iron at the end of pregnancy, a
further approximately 600 mg is required predominantly
in the last two trimesters. Iron stores of 600 mg mean that
the serum ferritin concentration in early pregnancy
(before inflammatory cytokines increase) needs to be
75–85 mg/l to prevent depletion of iron stores without
the need for supplementation.
The chances of achieving adequate iron status in
pregnancy are optimized if iron stores, assessed by serum
ferritin concentration, are adequate at the time of con-
ception, which can be affected by pregnancy spacing,
and if the diet has a high bioavailability of iron. Animal
studies suggest the foetal liver regulates several com-
ponents of iron balance including maternal absorption,
maternal storage of iron and placental transfer [50].
Although an elegant classical study demonstrated marked
increases in iron absorption (from 1 to 1.5 mg per day in
the first trimester to 5 mg per day in second trimester and
9 mg per day in the third trimester) [51], the World
Health Organization has not revised its recommendation
of approximately 60 mg per day supplemental iron for the
last 6 months of pregnancy [52]. However, routine iron
supplementation is questioned in many countries and
concerns have been expressed about whether additional
iron may be positively harmful for iron-replete pregnant
women and associated with gestational diabetes and
preeclampsia [53].
In older individuals, chronic blood loss, as a result of use
of NSAIDs (e.g. aspirin), gastrointestinal lesions or
cancer, is the most common cause of iron deficiency
[54]. Decreased production of gastric acid (hypochlorhy-
dria or achlorydria), which can be either age related or
drug induced, for example, by proton pump inhibitors,
negatively affects iron absorption by increasing iron
insolubility and therefore decreasing the bioavailability
of iron in the proximal duodenum [55]. In addition,
malabsorption conditions, such as those associated with
coeliac disease [56] and Helicobacter pylori infection [57],
can also compromise iron status.
Physiological response to iron depletion
As iron balance becomes negative, there is increased iron
release from ferritin. Ferritin depots fall, so tissue and
 630 Micronutrients

Table 2 Biomarkers of iron status in women and changes in pregnancy

Normal levels Changes in
Biomarker in women pregnancy Best use Advantages Limitations

Markers of functional iron status

Hb concentration 120–160 g/l First trimester: To determine severity Inexpensive and Not specific to iron
of anaemia and/or simple to deficiency
response to measure
treatment
115–140 g/l Low sensitivity
Second trimester: Indicates late stage of
iron depletion – does
not identify iron
deficiency. Influenced
by ethnicity, altitude,
smoking
97–148 g/l Unreliable in pregnancy
unless trimester
specific values are
used
Third trimester:
95–150 g/l
Note: normal or raised
Hb levels usually
indicate lack of
plasma expansion
RBC indices RBC count: RBC count: Abnormal Reflect availability Not specific to
4.2–5.4 million/ml 3.8–4.4 million/ml erythropoiesis. of iron over iron deficiency
previous
90–120 days
Identifies microcytic Late stage of iron
hypochromic depletion
anaemia; low SF
will confirm that
it is due to iron
deficiency
PCV: 37–47% PCV: 33–44% Note that increased Requires expensive
RDW usually automated flow
precedes other cytometry equipment –
markers of iron note that some of the
deficiency determinants of RBC
parameters can only be
measured on specific
brands of flow
cytometers
MCV: 84–99 MCV: 70–90
MCH: 27–32 pg MCH: 27–32 pg
(32–35 fl) (32–35 fl)
MCHC: 32–35 fl MCHC: 32–35 fl
Red cell distribution Red cell distribution
width (RDW): <14.5 width:
First trimester:

12.5–14.1%
Second trimester:
13.4–13.6%
Third trimester:
12.7–15.3%
Reticulocyte count: Reticulocyte count:
0.5–1% 1–2%
Markers of transport/supply
of iron to tissues
Serum iron 41–141 mmol/l First trimester: Short-term fluctuations:
diurnal variation and
increased after meat
ingestion
72–143 Serum iron is an acute
phase reactant to
inflammatory cytokines
Second trimester:
44–178
Third trimester:
30–193 mmol/l

Tf saturation 22–46% Values fall throughout Increases with

pregnancy but to iron overload
a lesser extent with
iron supplementation

(continued overleaf )

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 Iron deficiency in women Coad and Conlon 631

Table 2. (continued )

Normal levels Changes in

Biomarker in women pregnancy Best use Advantages Limitations

sTfR
ZPP
% Hypochromic red cells
Markers of iron in tissue
SF
Serum TIBC
Bone marrow iron 2–3
staining (Prussian blue)
(scored on six-point
scale: 0 is no detectable
iron, 1 is decreased iron,
2–3 is normal, 4–5
is iron increased)
Therapeutic trial
Potential markers
Hepcidin
2.8–8.5 mg/l >8.5 mg/l Increased levels indicate Reflects iron supply Assays are not well
early iron deficiency to cells and standardized so
as stores start to erythroid activity reference ranges are
become depleted not robust. Emerging
evidence suggests
levels are increased
in infection
Note that the use of Ethnic differences are
this marker is apparent
contentious in
pregnancy.
<70 mmol/mol Hb 60 mmol/mol Reflects iron delivery Affected by inflammation
to the developing but not usually seen
erythrocytes. during acute infection
because of time-lag in
producing ZPP-containing
cells
or
<80 mg/dl red cells
<6% Data not available Indicates
compromised
iron supply during
erythropoiesis
15–200 mg/l 30–150 mg/l To confirm depletion Positively correlated Serum ferritin is an acute
of iron stores in the with iron stores phase reactant to
absence of inflammation inflammatory cytokines
so markers of inflammation
should always be measured
Threshold levels are set Note pregnancy is
higher in the presence associated
of infection (>30 mg/l) with increases in
inflammatory
markers, especially
in the first and third
trimester
40–80 mmol/l First trimester: Raised in iron-
deficiency anaemia
42–73 mmol/l
Second trimester:
54–93 mmol/l
Third trimester:
68–107 mmol/l
1–2 To indicate depleted Considered to be Invasive and difficult
or absent body iron ‘gold standard’ of to collect
stores. Research use body iron stores
Limited ability to detect
development of iron
deficiency
Confirms iron deficiency
if response to oral iron
therapy (usually 200 mg
of ferrous iron per day)
is an increase in Hb
concentration of 20 g/l
in 3 weeks
Induced by inflammatory
cytokines

Hb, haemoglobin; MCH, mean corpuscular haemoglobin; MCHC, mean corpuscular haemoglobin concentration; MCV, mean corpuscular volume; PCV, packed cell
volume; RBC, red blood cell; RDW, red cell distribution width; SF, serum ferritin; sTfR, soluble transferrin receptor; Tf, transferrin; TIBC, total iron-binding capacity; ZPP,
zinc protoporphyrin. Adapted with permission from [21,39,40,41
,42].

serum ferritin levels decrease. However, concurrent
infection or inflammation will independently increase
serum ferritin levels. The raised ferritin level drives
hepcidin production, so iron absorption is not increased
despite a compromised iron status; this is the underlying
pathology of anaemia of chronic disease [58]. In the
absence of infection, decreased serum ferritin results in
upregulation of expression of DMT1 receptors and
ferroportin, so nonhaem iron transport is increased. Haem
iron transport is also increased. As tissue iron stores
become depleted, transferrin saturation falls below
15%, and the tissues increase the expression of transferrin
receptors in an attempt to procure more iron so soluble
TfR levels are elevated. With compromised delivery of

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 632 Micronutrients
iron to functional sites, normal erythropoiesis is disturbed
with smaller RBCs which have a greater variation in size
and reduced Hb content. In addition, there is increased
release of immature RBCs which contain more zinc
protoporphyrin (ZPP), so both ZPP and the ZPP : haem
ratio can be used to diagnose preanaemic iron deficiency
[59].
Consequences of iron deficiency
Research on the effects of IDWA has focussed on
children and effects of iron deficiency on myelination
and neurotransmitter production, because it was assumed
that iron levels in the brain were predetermined at the
time of closure of the blood brain barrier [60

]. However,
animal studies have suggested that iron deficiency also
has adverse effects in the adult brain [61]. Recent studies
suggest an association of iron deficiency with neuropsy-
chological consequences in women of reproductive age,
such as emotions, quality of life and cognition, including
memory and learning (reviewed in Ref. [60

]). Further-
more, iron supplementation in young women with
depleted tissue iron (defined as mild-to-moderate iron
deficiency in the absence of anaemia) has demonstrated
improvements in fatigue resistance, exercise perform-
ance and muscle function [62–64].
Iron deficiency in pregnancy, which is common, is
associated with maternal and infant complications includ-
ing low birthweight, prematurity, perinatal mortality,
increased risk of maternal infections and lowered
tolerance to blood loss and infection. In addition, it is
evident that maternal iron status may affect mother–
child interactions which can have implications for child
development [65].
Conclusion
Despite elucidation of many components of iron meta-
bolism, iron deficiency remains one the most common
nutritional problems in the world. Women are particularly
at risk because of the challenges of absorbing enough
additional iron to replace that lost in blood. Emerging
evidence suggests that depletion of iron stores may
affect neurocognitive function, even in adults before
erythropoiesis is compromised. This means that appro-
priate selection of biomarkers to determine early stages of
iron deficiency is essential not only to monitor effects of
iron depletion but also for early recognition of negative
iron balance and to identify the appropriate timing and
assessment of interventions. Although the sTfR : serum
ferritin ratio appears to be the biomarker of choice as
it reflects the prevalence and severity of IDA and is
sensitive to measuring the effectiveness of interventions,
it is currently limited by cost and problems with the
standardization and inter-assay variation of commercial
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
assays [66
], so Hb concentration and serum ferritin
(and concurrent measurement of CRP) have remained
the usual method of assessing iron status.
Chronic inflammatory conditions can result in reduced
iron absorption and increased sequestration of iron, thus
compromising iron status. That several biomarkers of
iron status are acute phase reactants means that caution
should be exercised in interpreting results in conditions
of chronic inflammation. There is a particular need to
determine how the biomarker profile is altered with
increased adiposity as the incidence of overweight
and obesity increases. In addition, the iron status of
hospitalized patients and the elderly may be similarly
compromised and difficult to interpret.
Acknowledgements
Conflicts of interest
The authors have been the recipients of funding for hosting educational
events from Pfizer and JC has received funding from the
Nutricia Research Foundation for research on complementary feeding
and iron.
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