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TOPLINE:

Iron deficiency anemia was identified in an additional 3.3 million US adults when the ferritin threshold was liberalized from ≤ 15 ng/mL, recommended by the World Health Organization (WHO), to ≤ 45 ng/mL, recommended by the American Gastroenterological Association (AGA), potentially leading to increased endoscopy referrals.

METHODOLOGY:

• In 2020, the AGA recommended bidirectional endoscopy for asymptomatic iron deficiency anemia in men and postmenopausal women, and conditionally in premenopausal women despite their higher likelihood of having the condition owing to menorrhagia.
• Researchers conducted a cross-sectional analysis of survey data from January to April 2025 to assess how many US adults had iron deficiency anemia using different recommendations for ferritin thresholds.
• They assessed ferritin and hemoglobin levels of 7357 nonpregnant US adults: 46.7% were men (median age, 46 years), 27.2% were premenopausal women (median age, 35 years), and 26.1% were postmenopausal women (median age, 63 years).
• Iron deficiency was defined as having ferritin levels ≤ 15 ng/mL (as per the WHO recommendation), ≤ 45 ng/mL (as per the AGA recommendation), or ≤ 30 ng/mL (intermediate threshold).
• Anemia was defined on the basis of WHO thresholds as having hemoglobin levels ≤ 12 g/dL in women and ≤ 13 g/dL in men.

TAKEAWAY:

• Median ferritin levels were 43 ng/mL in premenopausal women, 98 ng/mL in postmenopausal women, and 145 ng/mL in men.
• At a ferritin threshold of ≤ 15 ng/mL, 5.9 million adults were classified as having iron deficiency anemia; using a ≤ 30 ng/mL threshold, 8.3 million adults were identified with the condition.
• Using a ferritin threshold of ≤ 45 ng/mL, the researchers identified 9.2 million adults with iron deficiency anemia, with more than half of the new diagnoses in premenopausal women.
• An additional 0.8 million postmenopausal women, 0.7 million men, and 1.8 million premenopausal women would be recommended as per the AGA guidelines for evaluation by bidirectional endoscopy.

IN PRACTICE:

“When uncertain, revisiting the potential sources of IDA [iron deficiency anemia] — nutritional deficiency, malabsorption, GI [gastrointestinal] blood loss, or non-GI blood loss — can help direct the next steps in evaluation. A disciplined approach helps balance vigilance for serious disease against the value of endoscopy, ensuring patients receive appropriate care without unnecessary burden,” experts wrote in an accompanying commentary.

SOURCE:

This study was led by Omar Al Ta’ani, MD, of Allegheny Health Network in Pittsburgh. It was published online on August 25, 2025, in JAMA Internal Medicine.

LIMITATIONS:

The survey did not capture gastrointestinal symptoms such as hematochezia; thus, the analysis may have overestimated the number of additional endoscopies recommended by the guidelines.

DISCLOSURES:

This study received funding through multiple grants from the National Institute of Diabetes and Digestive and Kidney Diseases and the National Institute on Aging. Several authors reported receiving grants or personal fees from multiple sources, including the National Institutes of Health National Research Service Award T32 training program, Blueprint Medicines, and the American Society of Hematology. Three authors reported being employees of the US Department of Veterans Affairs.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.