Doctors Say Fatigue, Dizziness, Headaches, Feeling Cold and Poor Concentration May Signal Low Iron Stores Even Before Anaemia Develops.
New clinical guidance on iron deficiency is drawing greater attention to ferritin levels and symptoms that may emerge even before anaemia develops.
The American Society of Hematology (ASH) issued updated evidence-based guidance on September 16, recommending higher ferritin thresholds to help healthcare professionals detect iron deficiency earlier and more accurately. Ferritin is a protein that stores iron and is commonly measured to assess the body’s iron reserves.
Under the new guidance, a serum ferritin level of 30 nanograms per millilitre (ng/mL) or lower is recommended as the diagnostic threshold for adults, including menstruating and pregnant individuals.
For higher-risk groups, including people experiencing heavy menstrual bleeding and pregnant patients with anaemia, the recommended threshold is 50ng/mL or lower.
Among adults with inflammation, including those with cancer, inflammatory bowel disease or an infectious illness, the guidance recommends a ferritin level below 100ng/mL or transferrin saturation below 20 per cent.
For children aged between nine months and four years, the recommended ferritin threshold is 20ng/mL or lower.
Dr Malaz Yabrodi, Specialist in Internal Medicine at Medcare Shaikh Saqr Al Qasimi Hospital in Sharjah, said the medical approach to understanding iron deficiency has become increasingly nuanced.
“Ferritin is commonly used as a marker of the body’s stored iron, but ferritin should not be interpreted on its own,” Dr Yabrodi said. “It needs to be considered alongside symptoms and other blood tests.”
Previously, a ferritin result that fell within a laboratory’s reference range may have been viewed as an indication that a person had sufficient iron stores. However, clinicians increasingly recognise that the body’s iron reserves can become depleted before haemoglobin falls to levels associated with anaemia, Dr Yabrodi explained.
“This means that symptoms and the wider clinical picture should not be overlooked simply because the haemoglobin level is still within the normal range,” Dr Yabrodi said.
Why a normal result may not tell the whole story
According to Dr Yabrodi, laboratory reference ranges should not necessarily be viewed as the ideal target for every individual. Ferritin levels can be affected by factors such as inflammation, infection and certain medical conditions, making it important for doctors to consider the patient’s broader clinical picture when interpreting results.
“Because inflammation and infection can raise ferritin levels, a normal result does not always rule out iron deficiency,” Dr Yabrodi said.
The ASH guidance reflects this distinction by recommending a higher ferritin threshold for adults with inflammation. It also allows transferrin saturation — a measure related to iron transport and availability in the body — to be considered when diagnosing iron deficiency.
Warning signs of depleted iron stores
Iron plays an essential role in producing haemoglobin, the protein responsible for carrying oxygen throughout the body. It also supports normal energy metabolism as well as physical and cognitive function, Dr Yabrodi explained.
As iron stores decline, some people may begin experiencing symptoms even before anaemia develops. These can include fatigue, low energy, difficulty concentrating, headaches, dizziness, feeling unusually cold and reduced tolerance for exercise.
Shortness of breath is more commonly associated with iron-deficiency anaemia, particularly when haemoglobin levels have fallen significantly. Some people may also experience increased hair shedding or changes in their nails.
However, Dr Yabrodi stressed that these symptoms are not unique to iron deficiency and may have several other causes.
“They should not automatically be attributed to low iron,” the doctor said. “The important message is that both very low and excessively high iron levels can be problematic. The aim is not simply to have the highest possible ferritin level, but to maintain an appropriate level for your individual needs and health circumstances.”
A balanced diet is the starting point
For most people, maintaining healthy iron levels starts with eating a balanced and varied diet. Iron-rich foods include lean meat, poultry and seafood, along with plant-based sources such as beans, lentils, tofu, dark green vegetables, nuts, seeds and iron-fortified foods.
Pairing plant-based sources of iron with foods rich in vitamin C can help improve the body’s absorption of iron, Dr Yabrodi said.
However, diet is only one factor. Iron deficiency can result from inadequate dietary intake, increased iron requirements, blood loss, heavy menstrual periods, pregnancy or difficulties absorbing iron.
“In adults, particularly when iron deficiency is unexplained or persistent, it is important to consider possible sources of blood loss and other underlying causes rather than assuming that diet alone is responsible,” Dr Yabrodi said.
Why people should not self-prescribe iron
People experiencing persistent symptoms or whose blood tests indicate low ferritin levels should discuss their results with a doctor. A healthcare professional can assess whether additional testing is necessary and determine whether dietary changes, iron supplements or further investigation into an underlying cause may be appropriate.
“Iron supplements are not something everyone needs, and taking them unnecessarily can also cause side effects and, in some circumstances, lead to excessive iron accumulation,” Dr Yabrodi said.
The new ASH recommendations are intended as diagnostic thresholds rather than individual targets for ferritin levels. The organisation said separate guidance covering the treatment of iron deficiency is expected to be released in 2027.
“Ultimately, maintaining healthy iron stores is about looking at the whole person rather than focusing on a single number,” Dr Yabrodi said. “Regular medical review, a balanced diet and addressing the underlying cause of any deficiency are the most sensible approach.”
