New clinical guidelines regarding iron deficiency have shifted the focus to ferritin levels and symptoms that may appear even before anemia develops.
The American Society of Hematology (ASH) released new evidence-based recommendations on September 16th, stipulating higher ferritin thresholds for earlier and more accurate detection of iron deficiency. Ferritin is a protein responsible for iron storage and is often measured when assessing an individual's iron stores.
According to these guidelines, the diagnostic threshold for adults, including pregnant women and menstruating women, is a serum ferritin level of 30 nanograms per milliliter or lower. For high-risk groups, such as individuals with heavy menstrual bleeding and pregnant patients with anemia, the threshold is set at 50 ng/ml or lower.
For adults suffering from inflammation, including cases of cancer, inflammatory bowel disease, or infectious diseases, the guideline recommends a ferritin level below 100 ng/ml or a transferrin saturation below 20 percent. For children aged nine months to four years, the recommended ferritin threshold is 20 ng/ml or lower.
Dr. Malaz Yabrodi, an internal medicine specialist at Medcare Shaikh Saqr Al Qasimi Hospital in Sharjah, noted that the medical understanding of iron deficiency has become more complex. Dr. Yabrodi emphasized that while ferritin is often used as an indicator of body iron stores, it cannot be interpreted in isolation; symptoms and results from other blood tests must also be considered.
Previously, a ferritin result falling within the laboratory's reference range could be considered a sign of adequate iron stores. However, clinicians are increasingly realizing that stores can deplete before hemoglobin levels drop to a level associated with anemia. The doctor explained that the clinical picture and symptoms should not be ignored just because the hemoglobin level remains within normal limits.
In Dr. Yabrodi's opinion, laboratory reference ranges should not be viewed as the ideal target for every person. Ferritin can change due to infections, inflammations, and certain medical conditions, making the clinical context extremely important. He added that since inflammation and infections can raise ferritin levels, a normal result does not always rule out iron deficiency.
The ASH guidelines reflect this distinction by setting a higher ferritin threshold for adults with inflammation and allowing for the consideration of transferrin saturation—an indicator related to iron transport and availability for diagnosis. Dr. Yabrodi reminded that iron is critical for producing hemoglobin, which carries oxygen throughout the body, and also supports normal energy metabolism and cognitive and physical functions.
When iron stores are depleted, some people may experience symptoms before developing anemia. Warning signs include fatigue, low energy, difficulty concentrating, headaches, dizziness, cold sensation, and reduced tolerance to physical exertion. Shortness of breath is more commonly associated with iron deficiency anemia, especially with a significant drop in hemoglobin. Some may also notice increased hair loss or nail changes.
Nevertheless, Dr. Yabrodi warned that these symptoms are not specific to iron deficiency and can have many causes, so they cannot be automatically attributed to low iron content. The main message is that both very low and excessively high iron levels can be problematic; the goal is not simply to achieve the highest possible ferritin level, but to maintain an appropriate level for individual needs and health status.
For most people, maintaining healthy iron levels begins with varied and balanced nutrition. Sources of iron include lean meat, poultry, seafood, as well as legumes, lentils, tofu, dark green vegetables, nuts, seeds, and iron-fortified foods. Dr. Yabrodi also advised that combining plant-based iron sources with foods rich in Vitamin C can improve absorption.
However, diet is only one aspect of the problem. Iron deficiency can be linked to insufficient intake, increased needs, blood loss, heavy menstruation, pregnancy, or malabsorption issues. Dr. Yabrodi specifically noted that in adults, especially with unexplained or persistent deficiency, it is important to look for possible sources of blood loss and other underlying causes, rather than assuming that diet is solely to blame.
Individuals who continue to have symptoms or whose blood tests show low ferritin should discuss these results with a doctor. A healthcare professional can determine the need for additional tests, as well as the appropriateness of dietary changes, iron supplement intake, or investigation into the underlying cause. Dr. Yabrodi cautioned that iron supplements are not necessary for everyone, and unnecessary use can cause side effects or lead to excessive iron accumulation.
The new ASH guidelines represent diagnostic thresholds, not personal goals. The organization stated that a separate guideline on the treatment of iron deficiency is expected in 2027. In conclusion, Dr. Yabrodi stated that maintaining healthy iron stores requires a comprehensive approach to the individual, rather than focusing on a single indicator, and that the most sensible method is regular medical check-ups, balanced nutrition, and addressing the root cause of any deficiency.