But I’m Not Anemic … Understanding Iron Deficiency without Anemia
This year I’ve had more people than ever coming into the clinic asking about their newly diagnosed iron deficiency. It may sound strange, but I’m so excited to hear this! For years I have been highlighting lower than optimal ferritin levels on lab work that were considered normal.
So many people with classic symptoms of iron deficiency (mainly women) have been told that everything is fine, as though the absence of anemia means their iron status must be acceptable. The truth is more complicated.
Iron deficiency and anemia are not the same thing. You can have iron deficiency without anemia and in fact, this is very common. If iron deficiency persists long enough or becomes severe enough, it will eventually result in anemia. But symptoms start long before that and waiting until anemia develops means the situation has gone much too far.
Why Iron Matters
Iron is essential for much more than carrying oxygen in our red blood cells (although that’s foundational).
We need it for:
- Energy and stamina
- Mental clarity and focus
- Muscle function and exercise performance
- Healthy hair, skin, and nails
- A resilient immune system and normal healing
Women are vulnerable to low iron in particular because of menstrual blood loss, pregnancies, postpartum recovery, and often, dietary intake that doesn’t fully keep up with these demands.
Iron Deficiency Without Anemia: What It Can Look Like
Iron deficiency means your body’s iron stores (measured by ferritin) are depleted.
Anemia means your hemoglobin has dropped below a certain threshold.
Symptoms that can occur with iron deficiency (before anemia sets in) can include:
- Fatigue that doesn’t improve with rest
- Brain fog or trouble concentrating
- Reduced exercise tolerance
- Hair loss or brittle nails
- Restless legs
If these sound familiar, it’s worth asking whether iron deficiency could be playing a role, even if your hemoglobin is “normal.”
Why Iron Deficiency Gets Missed
The most common reason is that often only hemoglobin is measured on routine blood work to screen for anemia. If hemoglobin is within range, doctors may tell patients their iron status is fine, even if ferritin (iron storage) is low.
Another reason? Outdated reference ranges.
For decades, lab reference ranges for ferritin were set using samples of so-called “healthy” women but those groups included women who were iron deficient (and frankly, probably pushing through the day-to-day fatigue they considered normal). Iron deficiency is the most common nutrient deficiency worldwide, affecting an estimated 30–40% of women, largely due to the combination of menstrual losses and inadequate dietary intake to fully replace them.
Because no one asked (or quantified) how much blood women were losing in their cycles (and because many women don’t know what “normal” bleeding means) iron deficiency was inadvertently baked into the reference ranges. As a result, women could be told their ferritin was “normal,” when in reality it was far too low to be optimal.
This mistake is finally being corrected. After a huge advocacy effort in Ontario, the two largest labs (LifeLabs and Dynacare) implemented a higher clinical threshold for ferritin, effective September 2024. Ferritin’s clinical threshold is now at 30 µg/L (with anything under being defined as iron deficiency), which is better aligned with what patients actually need.
Interested in knowing more? Check out Raise the Bar website set up by the team who made the change happen!
Takeaway
If you’ve been told you’re “not anemic” but still feel unusually tired, foggy, or run down, you could still be iron deficient. Iron deficiency without anemia is real, common, and very treatable … once it’s recognized.
The good news is that proper testing and treatment can make a remarkable difference in energy, focus, and overall quality of life. And that is finally (finally!) easier than ever to achieve.
You don’t have to wait until anemia develops to be taken seriously.
Listen to last year’s episode of CBC’s The Current to hear a little more on the topic.
p.s. This is the first post in a series on lab tests that matter — the ones that too often get misinterpreted, overlooked, or under-explained. In future posts, we’ll explore more about iron as well as tests like vitamin D, cholesterol, and thyroid labs, so you’ll be better equipped to understand your results and advocate for your health.
