original article
Wien Klin Wochenschr
https://doi.org/10.1007/s00508-020-01661-6
HbA1c level decreases in iron deficiency anemia
Seher Çetinkaya Altuntaş · Mehtap Evran · Emel Gürkan · Murat Sert · Tamer Tetiker
Received: 8 October 2019 / Accepted: 9 April 2020
© Springer-Verlag GmbH Austria, part of Springer Nature 2020
Summary
Background Hemoglobin A1c (HbA1c) is the major
form of glycosylated hemoglobin. There are con-
flicting data on changes in HbA1c levels in patients
with iron deficiency anemia (IDA). The present study
aimed to investigate the effects of HbA1c levels in
the presence of IDA, the effects of iron treatment
on HbA1c levels, as well as the relationship between
the severity of anemia and HbA1c levels in patients
without diabetes.
Design and methods A total of 263 patients without di-
abetes mellitus (DM) who were admitted to Cukurova
University, Faculty of Medicine, Department of En-
docrinology and Hematology or who were followed
up in this clinic and diagnosed as having IDA were
included in the study. A total of 131 patients had IDA.
The control group comprised 132 age-matched and
sex-matched healthy individuals.
Results The mean HbA1c level was significantly lower
in the group with IDA (5.4%) than in the healthy con-
trol group (5.9%; p < 0.05). When the patients were
divided into three groups according to the sever-
ity of anemia through Hb levels, HbA1c levels were
observed to decrease as the severity of the anemia
S. Çetinkaya Altuntaş ()
Faculty of Medicine, Department of Internal Medicine,
Division of Endocrinology, Recep Tayyip Erdoğan University,
053100 Rize, Turkey
drsehercetinkaya@hotmail.com
M. Evran · M. Sert · T. Tetiker
Faculty of Medicine, Department of Internal Medicine,
Division of Endocrinology, Cukurova University, Adana,
Turkey
E. Gürkan
Cukurova University Medical Faculty, Department of
Internal Medicine, Division of Hematology, Adana, Turkey
K HbA1c level decreases in iron deficiency anemia
increased (5.5%, 5.4%, and 5%, respectively; p > 0.05).
The HbA1c levels of the patients with IDA were higher
after iron therapy (from 5.4 ± 0.5 to 5.5 ± 0.3; p = 0.057).
The mean hemoglobin (Hb), hematocrit (Hct), mean
cell volume (MCV), mean corpusculer hemoglobin
(MCH), and ferritin values also increased after iron
therapy (p < 0.05).
Conclusion The study results showed that IDA was
associated with low HbA1c levels, and increased after
iron therapy. Based on the study findings, it is neces-
sary to consider the possible effects of IDA on HbA1c
levels.
Keywords Hemoglobin A1c · Iron deficiency
anemia · Diabetes mellitus · Anemia · Iron therapy
Introduction
Hemoglobin A1c (HbA1c) is the most dominant frac-
tion of HbA1 and is formed by the glycation of the
valine amino acid in the β-chain of hemoglobin [1].
It reflects blood glucose levels over the past 3 months
and has been used in diagnosis of diabetes mellitus
(DM) for some time already according to ADA/EASD
guidelines. Also, HbA1c levels have a positive corre-
lation with hyperglycemia and its duration [2]. The
HbA1c formation used to assess glycemic status in
clinical practice depends on several factors, such as
the release of HbA1c in reticulocytes from bone mar-
row, the synthesis rate of HbA1c (or Hb glycosylation
rate), and the mean age of circulating erythrocytes
[3–5]. Detectable HbA1c levels are affected by plasma
glucose levels, the measurement method used, the
presence of variant hemoglobin affecting erythrocyte
recovery, hemolytic anemia, nutritional anemia, tha-
lassemia, uremia, pregnancy, and acute and chronic
hemorrhage.
 original article

Anemia is a very common problem worldwide. Table 1 Laboratory characteristics of patients with iron
According to the World Health Organization, iron de- deficiency anemia (case) and patients without anemia
ficiency anemia (IDA) is the most common nutritional (control)
deficiency [6–9]. Iron deficiency is still the most com- Variable Anemia Healthy control p
mon cause of anemia in Turkey [10]. Although IDA is n 131 132 0.14
very common, study results on the effect of IDA on Age (years) 39 ± 10 41 ± 9 0.17
HbA1c are still controversial. In several studies that Sex (male/female) 16/115 14/118 0.94
compared HbA1c levels before and after iron therapy Hb (g/dL) 11.545 ± 16 13.3 ± 0.9 0.000
in patients with IDA but without diabetes, HbA1c Hematocrit (%) 36.8 ± 4.64 39 ± 3.5 0.000
levels were found to be higher before treatment, and MCV (fL) 79 ± 10 87 ± 4 0.000
a significant decrease was observed after treatment
Ferritin (µg/mL) 6.6 ± 5.03 40 ± 52 0.000
[11–14]. In addition, patients with IDA without di-
HbA1c, % 5.4 ± 0.5 5.9 ± 0.5 0.000
abetes and a healthy control group had the same
HbA1c levels in some studies [15, 16]. Fasting glucose (mg/dL) 87 ± 7.6 87 ± 8.0 0.68
The underlying mechanisms and modes of action Note: Data are presented as mean ± SD unless otherwise specified
Hb hemoglobin, MCV mean cell volume, HbA1c hemoglobin A1c
of HbA1c levels in patients with IDA and anemia but
without diabetes are still controversial. The present
study aimed to investigate the changes in HbA1c levels males with Hb ≥11 g/dL and <13 g/dL), 2) moderate
in patients without diabetes who had IDA due to the anemia (Hb ≥8 g/dL and <11 g/dL, for both sexes) and
importance of HbA1c in the diagnosis and follow-up 3) severe anemia (Hb <8 g/dL, for both sexes). The
of DM, and due to the frequency of IDA as a clinical HbA1c results in each group were compared with the
finding. HbA1c results in the group without anemia.

Material and methods Statistical analysis

Study population Statistical analyses were performed using the SPSS

A total of 263 individuals consisting of 131 patients
(116 women, 15 men, mean age 39 ± 10 years) who
were diagnosed as having IDA and 132 healthy indi-
viduals (118 women, 14 men, mean age 41 ± 9 years)
who were admitted to Cukurova University, Faculty of
Medicine, Department of Endocrinology and Hema-
tology were included in the study. The control group
consisted of age-matched and sex-matched individ-
uals. Those who had impaired fasting glucose, DM,
hemoglobinopathy, hemolytic anemia, chronic alco-
hol use, chronic renal failure, chronic liver failure,
pregnancy, and breastfeeding history were excluded.
Hemoglobin, hematocrit, mean cell volume (MCV),
ferritin, insulin, fasting blood glucose, and HbA1c
were measured before iron therapy. All patients with
IDA were treated with elemental iron at a mean
dosage of 100 mg/day for 3 months. The HbA1c
level was measured using a Variant II Hemoglobin
Testing System (BIO-RAD, Hercules, CA, USA) instru-
ment with high-performance liquid chromatography
(HPLC). Tests were repeated following iron therapy.
The patients with anemia were then divided into
three groups according to the total Hb levels: 1) mild
anemia (females with Hb ≥11 g/dL and <12 g/dL and
version 20.0 software (IBM, Armonk, NY, USA). Cat-
egorical variables are expressed in numbers and per-
centages, whereas continuous variables are expressed
in mean and standard deviation (SD) and in median
and min–max, where appropriate. The χ2-test was
used to compare categorical variables between the
groups. Student’s t-test was used to compare con-
tinuous variables between the two groups. The paired
samples t-test was used to compare before-after treat-
ment variables. A p value of <0.05 was considered
statistically significant.
Results
Of the total 263 patients, the patient group con-
sisted of 131 patients with IDA and the control
group comprised 132 healthy individuals. The mean
age of patients with IDA was 39 ± 10 years (range:
19–72 years), and the mean age of the healthy con-
trols was 41 ± 9 years (range: 20–64 years) (Table 1).
The number of patients and sexes were similar in
both groups. As expected, hematologic parameters
between the two groups had significant differences.
Hemoglobin, Hct, MCV, and ferritin levels were lower
in the patients with anemia (p < 0.05). No difference

Table 2 HbA1c values ac- Variable No anemia Mild anemia Moderate anemia Severe anemia p
cording to the severity of
n 69 29 31 2 0.000
anemia (case)
HbA1c, % 5.6 ± 0.3 5.5 ± 0.50 5.4 ± 0.50 5± 0 0.45
Hb, g/dL 13.1 ± 1.3 11.9 ± 0.8 9.8 ± 0.8 6.9 ± 1.2 0.000
Note: Data are presented as mean ± SD unless otherwise specified
Hb hemoglobin, MCV mean cell volume, HbA1c hemoglobin A1c

HbA1c level decreases in iron deficiency anemia K


Table 3 Pretreatment and Variable
posttreatment variables
Hb, g/dL
Hct, %
MCV, fL
Ferritin, ng/mL
Fasting glucose, mg/dL
HbA1c, %
Note: Data are presented as mean ± SD unless otherwise specified
Hb hemoglobin, Hct hematocrit, MCV mean cell volume, HbA1c hemoglobin A1c
was seen between the fasting glucose levels in both
groups (p = 0.636). In the group with anemia, HbA1c
levels were statistically significantly lower (5.4 ± 0.5%
and 5.9 ± 0.5%). Of the patients 29 had mild anemia,
31 had moderate anemia, and 2 had severe anemia.
Anemia was not observed in 69 patients.
Based on the comparison of the severity of anemia
with the HbA1c levels, a decline in HbA1c levels was
observed as the hemoglobin levels decreased; how-
ever, this difference was not statistically significant
(HbA1c levels 5.6%, 5.5%, 5.4%, and 5%, respectively;
p > 0.05) (Table 2).
The HbA1c levels of the patients with IDA were
higher after iron therapy (from 5.4 ± 0.5 to 5.5 ± 0.3;
p = 0.057). The mean Hb, Hct, MCV, MCH, and fer-
ritin values also increased after iron therapy (p < 0.05)
(Table 3).
Discussion
Hemoglobin A1c is a glycosylated hemoglobin A1
molecule that shows blood glucose levels over the
past 3 months. It is influenced by several factors
such as hemolytic anemia, hemoglobinopathy, acute
and chronic hemorrhage, blood transfusion (reason
for storage conditions) [17], pregnancy, uremia, and
blood glucose. In recent years, however, it has be-
come an issue of concern as to how HbA1c levels
change in IDA, which is common and affects a signif-
icant part of the population [18]. The results in the
literature on the relationship between anemia and
HbA1c remain controversial. Brooks et al. showed
increased HbA1c levels in adults with IDA without
diabetes and decreased HbA1c levels after treatment
[11]. In a study by Hansen et al. normal HbA1c levels
were observed decreased after anemia treatment [12];
however, no change was observed in HbA1c levels of
adults without diabetes and no difference was found
after iron therapy [1, 19].
Unlike these studies, HbA1c levels were lower in
the group with anemia than in the healthy control
group in this study. Actually, although HbA1c levels
were slightly lower, they were still in the normal refer-
ence range, so they are not of great clinical relevance.
In a study by Nitin Sinha et al. [16] that included
50 patients, HbA1c was found to be similarly low in
the patient group with anemia, and HbA1c levels were
found to increase after 2 months of iron therapy. The
K HbA1c level decreases in iron deficiency anemia
original article
IDA group before treatment IDA group after treatment p
11.5 ± 1.6 12.2 ± 1.6 0.000
36.8 ± 4.64 38 ± 4.9 0.003
79 ± 10 82 ± 7.4 0.000
6.6 ± 5.03 15.1 ± 5 0.000
87 ± 7.6 90 ± 8.6 0.001
5.4 ± 0.5 5.5 ± 0.3 0.057
patients in the present study received oral iron ther-
apy for 3 months. There was a statistically increase in
borderline HbA1c levels after treatment. The reason
of the non-significant difference in this study may be
related with the oral iron therapy (100 mg/day ferrous
sulfate) for a limited period of 3 months; however,
a statistically significant improvement was observed
with Hb, Hct, and ferritin after treatment (Table 3).
This finding indicated that higher HbA1c levels can
be obtained if patients receive treatment for a longer
time of period (i.e., 6 months) for improved clinical
and laboratory results.
Several authors have suggested that the inconsis-
tent results between anemia and HbA1c were due to
the method used to measure HbA1c. In a study by
Goldstein et al. [20], HbA1c measured using HPLC
was increased 2h after a standard breakfast, and ery-
throcytes were incubated in 0.9% saline at 37 °C for 5h.
This increase was explained by the presence of insuffi-
cient HbA1c. Rai et al. investigated different methods
used for measuring HbA1c. They reported that HbA1c
levels were not different when they were measured
using colorimetric assays, ion exchange chromatog-
raphy, and affinity chromatography methods. In the
present study, HbA1c was studied using HPLC, which
is accepted as a safe and valid method.
The mechanisms causing an HbA1c increase or
decrease are not clear. According to studies that
showed an increase in HbA1c levels, the globin chain
was more easily glycosylated due to changes in the
hemoglobin structure quaternary in IDA and iron de-
ficiency. It is suggested that the HbA1c concentration
increases linearly with the age of each erythrocyte
due to this irreversible process [11, 21]. Coban et al.
reported that the higher HbA1c levels in IDA could be
explained by an increase in the glycolytic fraction due
to the decrease in hemoglobin concentration when
the serum glucose is constant. Van Heyningen et al.
[19], who were among the researchers who found
that HbA1c levels did not change with anemia, re-
ported that both mature and immature erythrocytes
were minimally affected by the minimal effect of the
hemolytic component in IDA, and thus the erythro-
cyte life span was normal. Hansen et al. demonstrated
that there were no significant differences in HbA1c
concentrations in patients with iron deficiency and
vitamin B12 deficiency and healthy controls. This can
be attributed to the fact that the reason for normal
 original article
HbA1c levels is the absence of the hemolytic compo-
nent in IDA, and the presence of a minimal hemolytic
component in B12 deficiency.
Based on the severity of anemia, the groups with
mild anemia, moderate anemia, severe anemia, and
groups without anemia had a non-significant de-
crease in HbA1c levels when the hemoglobin levels
were decreased. The reason for not having a statis-
tically significant decrease was probably due to the
limited number of patients and that the number of
individuals between the groups was different (there
were only two patients in the group with severe ane-
mia). Hematologic parameters (Hb, Hct, MCV, and
ferritin) at the end of the third month of the treat-
ment statistically increased, and HbA1c levels showed
a borderline significant increase. In another study, Ju-
liana et al. [22] reported that HbA1c results could be
affected by the severity of anemia and HbA1c could
be used in the diagnosis and follow-up of patients
with mild anemia and diabetes.
Study limitations
One of the limitations of the study is the inhomoge-
neous distribution of the subjects in the study groups.
Another limitation is that there were only two pa-
tients in the severe anemia group. An important other
limitation is its relatively short duration, because a
3-month follow-up is not sufficient for a chronic dis-
ease such as IDA, which requires a longer treatment
period. In the patients, IDA was still continuing at the
end of the third month; however, at the end of the
sixth month, the laboratory parameters were unable
to be studied.
Conclusion
It is not possible to fully explain the relationship be-
tween the presence of IDA, anemia level, and decreas-
ing HbA1c. Most likely, decreased erythrocyte indices,
decreased erythrocyte life span, and altered morphol-
ogy play a role. Although IDA is the most common
nutritional deficiency, the results and mechanisms are
still unclear. When considering the prevalence of IDA
in society and the common use of HbA1c, how ane-
mia affects HbA1c has become an important issue.
Unlike other studies, HbA1c levels were assessed in
patients with anemia and in a healthy control group
before and after treatment in this study. The relation-
ship between anemia severity and HbA1c levels was
also assessed. Nonetheless, further large-scale, long-
term studies with homogeneous patient groups are
required to establish a conclusion.
Compliance with ethical guidelines
Conflict of interest S. ÇetinkayaAltuntaş, M. Evran, E. Gürkan,
M. Sert, and T. Tetiker declare that they have no competing
interests.
HbA1c level decreases in iron deficiency anemia
Ethical standards The study protocol was approved by the
Ethics Committeeof Faculty of MedicineNon-invasiveClinical
Trials Ethics Committee of Cukurova University (No: 51/Date:
04.03.2016). Written informed consent was obtained from
each participant. The study was conducted in accordance
with the principles of the Declaration of Helsinki.
References
1. Kim C, Bullard KM, Herman WH, Beckles GL. Associa-
tion between iron deficiency and A1C levels among adults
without diabetes in the national health and nutrition exam-
ination survey, 1999-2006. Diabetes Care. 2010;33:780–5.
2. UK Prospective Diabetes Study Group. Intensive blood-
glucose control with sulphonylureas or insulin compared
with conventional treatment and risk of complications in
patients with type 2 diabetes. Lancet. 1998;352:837–53.
3. Telen MJ, Kaufman RE. The mature erythrocyte. In: Greer JP,
Forester J, et al., editors. Wintrobe’s clinical hematology.
11th ed. Philadelphia, PA: Lippincott Williams and Wilkins;
2004. p. 230.
4. Saudek CD, Herman WH, Sacks DB, Bergenstal RM, Edel-
man D, Davidson MB. A new look at screening and di-
agnosing diabetes mellitus. J Clin Endocrinol Metab.
2008;93:2447–53.
5. International Expert Committee. International expert
committeereporton theroleof A1Cassay in thediagnosisof
diabetes. Diabetes Care. 2009;32:1327–34.
6. Ioannou GN, Spector J, Scott K, Rockey DC. Iron deficiency
and gastrointestinal malignancy. A population-based co-
hort study. Am J Med. 2002;113:281–7.
7. Wu AC, Lesperance L, Bernstein H. Screening for iron
deficiency. Pediatr Rev. 2002;23:171–8.
8. DeMaeyerEM,Adiels-TegmanM.Theprevalenceofanemia
in the world. World Health Stat Q. 1985;38:302–16.
9. Peterson KP, Pavlovich JG, Goldstein D, Little R, England J,
Peterson CM. What is hemoglobin A1c? An analysis of gly-
cated hemoglobins by electrospray ionization mass spec-
trometry. Clin Chem. 1998;44:1951–8.
10. Duffy TP. Mikrositik ve hipokromik anemiler. In: Gold-
man L, Ausiello D, editors. Cecil textbook of medicine.
İstanbul: Güneş Kitabevi; 2006. pp. 1003–8.
11. Brooks AP, Metcalfe J, Day JL, Edwards MS. Iron de-
ficiency and glycosylated haemoglobin A1. Lancet.
1980;316(8186):141.
12. Gram-Hansen P, Eriksen J, Mourits-Andersen T, Olesen L.
Glycosylated haemoglobin (HbA1c) in iron- and vitamin
B12 deficiency. J Intern Med. 1990;227(2):133–6.
13. Coban E, Ozdogan M, Timuragaoglu A. Effect of iron defi-
ciency anemia on the levels of hemoglobin A1c in nondia-
betic patients. Acta Haematol. 2004;112(3):126–8.
14. El-Agouza I, Abu Shahla A, Sirdah M. The effect of iron
deficiency anaemia on the levels of haemoglobin subtypes:
possible consequences for clinical diagnosis. Clin Lab
Haematol. 2002;24(28):285–9.
15. Ford ES, Cowie CC, Li C, Handelsman Y, Bloomgarden ZT.
Iron-deficiency anemia, non-iron-deficiency anemia and
HbA1c among adults in the US. J Diabetes. 2011;3:67–73.
16. Sinha N, Mishra TK, Singh T, Gupta N. Effect of iron defi-
ciency anemia on hemoglobin A1c levels. Ann Lab Med.
2012;32(1):17–22. https://doi.org/10.3343/alm.2012.32.1.
17.
17. Prosenz J, Öhlinger T, Müllner EW, et al. Glycated
hemoglobin concentrations of red blood cells minimally
increase during storage under standard blood banking
conditions. Transfusion. 2019;59(2):454–445.
K
 original article

18. Eberentz-Lhomme C, Ducrocq R, Intrator S, Elion J,

Nunez E, Assan R. Haemoglobinopathies: a pitfall in the
assessment of glycosylated haemoglobin by ion-exchange
chromatography. Diabetologia. 1984;27:596–8.
19. van Heyningen C, Dalton RG. Glycosylated haemoglobin in
iron-deficiency anaemia. Lancet. 1985;1(8433):874.
20. Goldstein DE, Peth SB, England JD, Hess RL, DaCosta J. Ef-
fects of acute changes in blood glucose on HbA1c. Diabetes.
1980;29(8):623–8.
21. Sluiter WJ, van Essen LH, Reitsma WD, Doorenbos H.
Glycosylated haemoglobin and iron deficiency. Lancet.
1980;2(8193):531–2.
22. Silva JF, Pimentel AL, Camargo JL. Effect of iron deficiency
anaemia on HbA1c levels is dependent on the degree of
anaemia. Clin Biochem. 2016;49:117–20.
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K HbA1c level decreases in iron deficiency anemia