One of the main causes of anaemia is iron deficiency. Anaemia is when you do not have enough healthy red blood cells to carry oxygen around your body. Red blood cells contain a protein called haemoglobin, which, in turn, contains iron.
A negative iron balance in the body can result in reduced iron stores necessary for sustaining healthy haemoglobin levels. While iron deficiency anaemia is an important condition, iron deficiency by itself is also a considerable health issue that is often neglected.
Identifying the root causes of iron deficiency and addressing them directly is essential for improving patient outcomes. Recent research has shown that even mild iron deficiency – marked by serum ferritin levels lower than 20-35 µg/L – can lead to various symptoms. Often overlooked or ignored, these symptoms include:
- Fatigue – experiencing tiredness even after adequate sleep
- Weakness – notable fatigue during physical activities
- Difficulty concentrating – challenges in maintaining focus
- Poor mood – a general sense of unhappiness
- Hair thinning or loss – noticeable decrease in hair density
- Brittle or ridged nails – nails that are easily damaged or have an uneven surface
- Restless legs – an uncontrollable and often uncomfortable urge to move the legs
- Foggy thinking – mental cloudiness or lack of clarity
- Reduced exercise performance – decreased ability to perform physical activities
- Poor work productivity – lower efficiency in professional tasks.
Certain groups are particularly vulnerable to developing mild iron deficiency, including:
- Growing children
- Pregnant and menstruating women
- Endurance athletes
- Older adults.
Given the potential health implications of mild iron deficiency, proactive management of this condition is essential.
Eating for iron
To maximise iron intake, it is advisable to adopt a two-pronged strategy that includes both heme and non-heme iron sources. Heme iron, found mainly in animal products like liver, red meat, seafood and poultry, is absorbed more efficiently than non-heme iron, which is derived from plant-based foods.
Vegetarians can maintain sufficient iron levels by consuming a varied diet rich in non-heme iron from whole grains, legumes, nuts, seeds, dried fruits and leafy greens. Nevertheless, dietary changes alone may not sufficiently address iron deficiency.
It is recommended to minimise the intake of iron absorption inhibitors such as tea, coffee, cocoa and red wine, particularly for individuals without symptoms who have no absorption issues.
As a supplement
Iron supplementation has been shown to be both effective and safe for most patients, especially through oral ferrous iron preparations. For individuals showing symptoms or those at risk for anaemia, oral iron supplementation is the preferred and most accessible therapeutic option.
In Malaysia, a variety of iron supplements are available, with ferrous salts — such as ferrous fumarate, sulphate and gluconate — being the most frequently recommended due to their superior absorption characteristics. Clinical guidelines recommend taking iron supplements either one hour before or two hours after meals to enhance absorption.
However, flexibility may be necessary to ensure adherence to the regimen.Alternate-day dosing (60–200 mg, adjusted for tolerance) has been linked to better tolerability and compliance, compared to daily dosing. Despite the benefits of oral supplementation, gastrointestinal side effects can impede adherence.
These can include nausea, abdominal discomfort and diarrhoea. Controlled-release formulations and iron polymaltose complexes typically cause fewer gastrointestinal issues, although the higher cost of iron polymaltose may limit its availability. Traditionally, it has been advised to consume vitamin C alongside oral iron to improve absorption.
However, recent studies suggest that this practice may not be essential, indicating no significant differences in serum ferritin levels after eight weeks of treatment.
Rapid intake
Oral iron supplements are generally the first line of treatment for non-anaemic iron deficiency. However, oral iron may cause side effects, may not be suitable for certain types of iron deficiency, and can take a considerable amount of time to become effective.
Newer iron formulations, such as intravenous (IV) iron, offer improved stability, fewer adverse reactions and quicker benefits. It is critical to avoid IV iron in patients with active systemic infections to reduce the risk of promoting microbial growth and compromising immune function. Indications for IV iron therapy include:
- Ineffective oral therapy or poor adherence
- Conditions that result in malabsorption (e.g. coeliac disease, post-bariatric surgery)
- Inflammatory bowel disease (IBD)
- Chronic kidney disease in patients receiving erythropoiesis-stimulating agents
- Situations requiring rapid iron replenishment (e.g. pre-operative preparations or post-haemorrhage)
- Heart failure.
Monitoring a must
After a treatment course of oral iron supplements lasting 60 to 90 days, it is vital to reassess the person’s iron status through fasting iron studies one week post-therapy. Blood specimens should be collected in the morning following an overnight fast, as well as no oral iron supplements at least 24 hours prior to testing. If the iron level is still insufficient, further investigation is necessary.
Iron studies should also be repeated around 60 to 90 days after IV iron administration, or sooner if clinically warranted. If patients do not respond to oral iron therapy or if iron deficiency recurs, further evaluations must be conducted to rule out potential blood loss or malabsorption issues.
A decrease in haemoglobin levels may be clinically significant and could require referrals to specialists such as gynaecologists or gastroenterologists based on the findings.
A proactive step
Iron deficiency without anaemia is a condition that is often underestimated and frequently misdiagnosed, warranting greater attention. Increasing evidence suggests that proactive prevention and treatment of even mild iron deficiency is essential for supporting health and development across various demographics.
Healthcare providers must remain vigilant in identifying and addressing iron deficiency without anaemia to improve health outcomes for their patients.
Taking a proactive approach to iron deficiency before the onset of anaemia can significantly enhance a patient’s quality of life, although the supporting evidence for this stance varies. Effective management of iron deficiency relies on thorough identification and investigation of underlying causes.
For uncomplicated cases, oral iron serves as an accessible, effective, safe and cost-effective solution. Conversely, for patients who cannot tolerate oral iron or those with conditions making oral therapy ineffective or risky, IV treatment should be considered as the preferred alternative.
By Datuk Dr Nor Ashikin Mokhtar
Published in Star Newspaper, 24 Feb 2025
