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Background: The global diabetes mellitus burden is increasing. Developing countries, including the majority of Middle Eastern countries, are experiencing an acceleration in this issue. We investigated the effects of Iron Deficiency Anemia on HbA1c levels in diabetic adults in Saudi Arabia.
Method: A retrospective, cross sectional single-center study was conducted in the period January to April 2023. 445 individuals aged 18 and over received medical care at the polyclinics of King Faisal University are included. Demographic data and clinical condition information were extracted from electronic medical records.
Results: among our patients, 41 patients were diabetic and the other 404 were not. The diabetic patients were significantly older than normal individuals (mean = 57 years among diabetics versus 43.6 years among non-diabetics). Non-diabetic anemic patients showed significantly higher levels of HB A1C compared to the non-diabetic not anemic patients. The median of HBA1C among the non-diabetic anemic patients was 5.46 compared to 5.1 in the non-diabetic not anemic patients (p <0.001). The same finding had been noticed among the diabetic patients, (median of HB A1C = 7.9% in anemic patients versus 6.91 % in non-anemic patients). Nevertheless, this variation didn’t reach the level of statistical significance (p = 0.249).
Conclusion: iron status must be considered when interpreting HbA1c in both diabetic and non-diabetic individuals our data also imply that clinicians should be careful when identifying both diabetes and prediabetes in anemic patients. In non-diabetics, iron deficiency anemia features are considerably linked with HbA1c. Hence, its variables should be assessed before diagnosing diabetes.
2. Meo SA. Prevalence and future prediction of type 2 diabetes mellitus in the Kingdom of Saudi Arabia: A systematic review of published studies. J Pak Med Assoc. 2016 Jun;66(6):722-5.
3. Cetinkaya Altuntas S, Evran M, Gurkan E, Sert M, Tetiker T. Hba1c Level Decreases in Iron Deficiency Anemia. Wien Klin Wochenschr 2021;133(3-4):102-106. doi: 10.1007/s00508-020-01661-6
4. Yuan Y, Zhou X, Jia W, Zhou J, Zhang F, Du J, et al. The Association between Self-Monitoring of Blood Glucose and Hba1c in Type 2 Diabetes. Front Endocrinol (Lausanne) 2023;14(1056828. doi: 10.3389/fendo.2023.1056828
5. Association AD. 2. Classification and Diagnosis of Diabetes. Diabetes care 2016;39(Supplement_1):S13-S22
6. Van’t Riet E, Alssema M, Rijkelijkhuizen JM, Kostense PJ, Nijpels G, Dekker JM. Relationship between A1c and Glucose Levels in the General Dutch Population: The New Hoorn Study. Diabetes care 2010;33(1):61-66.
7. Ahmad J, Rafat D. Hba1c and Iron Deficiency: A Review. Diabetes Metab Syndr 2013;7(2):118-122. doi: 10.1016/j.dsx.2013.02.004
8. Yasuno T, Maeda T, Tada K, Takahashi K, Ito K, Abe Y, et al. Effects of Hba1c on the Development and Progression of Chronic Kidney Disease in Elderly and Middle-Aged Japanese: Iki Epidemiological Study of Atherosclerosis and Chronic Kidney Disease (Issa-Ckd). Intern Med. 2020;59(2):175-1803. doi: 10.2169/ internalmedicine.3242-19
9. Soliman AT, De Sanctis V, Yassin M, Soliman N. Iron deficiency anemia and glucose metabolism. Acta Biomed. 2017;88(1):112–8.
10. Organization WH. Micronutrient deficiencies 2020. https://www.who.int/nutrition/topics/ida/en/. Accessed 10 June 2020.
11. Alenazi AMG, Al-Saeed AH, Ghneim H, and Shaik AP (2017). Effect of iron deficiency anemia on glycosylated hemoglobin level (HbA1c) in non-diabetic patients in Riyadh region of Saudi Arabia. International Journal of Advanced and Applied Sciences, 4(1): 59-66 .
12. Schindler C, Birkenfeld AL, Hanefeld M, Schatz U, Köhler C, Grüneberg M, et al. Intravenous ferric carboxymaltose in patients with type 2 diabetes mellitus and iron deficiency: CLEVER trial study design and protocol. Diabetes Ther [Internet]. 2018;9(1):37– 47. Available from: http://dx.doi.org/10.1007/s13300-017-0330-z
13. Finch C. Regulators of iron balance in humans. Blood. 1994;84(6):1697–702. 15.
14. Abbaspour N, Hurrell R, Kelishadi R. Review on iron and its importance for human health. J Res Med Sci. 2014;19(2):164–74.
15. Christy AL, Manjrekar PA, Babu RP, Hegde A, Rukmini MS. Influence of iron deficiency anemia on hemoglobin A1c levels in diabetic individuals with controlled plasma glucose levels. Iran Biomed J. 2014;18(2):88–93. Available from: http://dx.doi.org/10.6091/ibj.1257.2014
16. Hashimoto K, Noguchi S, Morimoto Y, Hamada S, Wasada K, Imai S, et al. A1C but not serum glycated albumin is elevated in late pregnancy owing to iron deficiency. Diabetes Care. 2008;31(10):1945–8
17. World Health Organization. Haemoglobinconcentrations for the diagnosis of anaemia andassessment of severity. World Health Organization. 2011;1-6.
18. American Diabetes Association. 6. Glycemic targets: Standards of medical care in diabetes‑2018. Diabetes Care 2018;41:S55‑64
19. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-34
20. Horton BF, Huisman TH. Studies on the heterogeneity of haemoglobin. vii. Minor haemoglobin components in haematological diseases. Br J Haematol 1965;11:296-304.
21. Ford ES, Cowie CC, Li C, Handelsman Y, Bloomgarden ZT. Iron-deficiency anemia, noniron-deficiency anemia and HbA1c among adults in the US. J Diabetes 2011;3:67-73.
22. Intra J, Limonta G, Cappellini F, Bertona M, Brambilla P. Glycosylated Hemoglobin in Subjects Affected by Iron-Deficiency Anemia. Diabetes Metab J. 2019;43(4):539.
23. Kuang L, Li W, Xu G, You M, Wu W, Li C. Systematic review and meta-analysis: influence of iron deficiency anemia on blood glycosylated hemoglobin in diabetic patients. Ann Palliat Med. 2021 Nov;10(11):11705-13.
24. Brooks AP, Metcalfe J, Day JL, Edwards MS. Iron deficiency and glycosylated haemoglobin A1. Lancet.1980;316(8186):141.
25. Gram-Hansen P, Eriksen J, Mourits-Andersen T, Olesen L. Glycosylated haemoglobin (HbA1c) in iron- and vitamin B12deficiency. J InternMed. 1990;227(2):133–6.
26. Coban E, Ozdogan M, Timuragaoglu A. Effect of iron deficiency anemia on the levels of hemoglobin A1c in nondiabeticpatients. ActaHaematol. 2004;112(3):126–8.
27. El-Agouza I, Abu Shahla A, Sirdah M. The effect of iron deficiency anaemia on thelevels of haemoglobin subtypes: possible consequences for clinical diagnosis. Clin Lab Haematol. 2002;24(28):285–9.
28. Guo W, Zhou Q, Jia Y, et al. Increased Levels of Glycated Hemoglobin A1c and Iron Deficiency Anemia: A Review. Med Sci Monit 2019; 25: 8371–8378. DOI: 10.12659/MSM.916719.
29. Attard SM, Herring AH, Wang H, et al. Implications of iron deficiency/anemia on the classification of diabetes using HbA1c. Nutr Diabetes 2015; 5: e166. DOI: 10.1038/ nutd.2015.16.
30. English E, Idris I, Smith G, Dhatariya K, Kilpatrick ES, John WG. The effect of anemia and abnormalities of erythrocyte indices on HbA1c analysis: a systematic review. Diabetologia 2015;58:1409-21
31. Silva JF, Pimentel AL, Camargo JL. Effect of iron deficiency anemia on HbA1c levels is dependent on the degree of anemia. Clin Biochem 2016;49:117-20.
32. Grossman A, Gafter-Gvili A, Schmilovitz-Weiss H, KorenMorag N, Beloosesky Y, Weiss A. Association of glycated hemoglobin with hemoglobin levels in elderly nondiabetic subjects. Eur J Intern Med 2016;36:32-5.
33. Purbey R, Agrawal BK, Kaushal P, Kela R, Thomas A. A Study on the Effect of Iron Deficiency Anaemia on Haemoglobin A1c Levels in Non-Diabetic Adults. jemds. 2020 May 25;9(21):1649-53.
34. Sinha N, Mishra TK, Singh T, Gupta N. Effect of iron deficiency anemia on hemoglobin A1c levels. Ann Lab Med 2012;32:17-22.
35. Rajagopal L, Ganapathy S, Arunachalam S, et al. Does Iron Deficiency Anaemia and its Severity Influence HbA1C Level in Non Diabetics? An Analysis of 150 Cases. J Clin Diagn Res 2017; 11: EC13–EC15. DOI: 10.7860/JCDR/2017/25183.9464.
36. Bindayel IA. Influence of iron deficiency anemia on glycated hemoglobin levels in non-diabetic Saudi women. J Int Med Res. 2021 Feb;49(2):030006052199015.
37. Vishal K, Kodliwadmath M and Harish B. Effect of iron deficiency anemia on glycosylated hemoglobin levels in non diabetic Indian adults. Int J Med Health Sci 2014; 3: 40–43
38. Bharadwaj K, Sharma SK, Rajpal N, et al. Effect of iron deficiency anaemia on haemoglobin A1c levels. Ann Clin Lab Res 2016;4:4.
39. Aggarwal S, Kakkar R, Kaushik RM. Iron deficiency anaemia- does it affect the glycosylated haemoglobin levels in non- diabetic patients? J Adv Res Med 2014;1(3&4):1-6.
40. Gould BJ, Davie SJ, Yudkin JS. Investigation of the mechanism underlying the variability of glycated haemoglobin in non-diabetic subjects not related to glycaemia. Clin Chim Acta. 1997;260:49–64
41. Li J, Liu B, Liu C. [Erythrocyte membrane lipid peroxidation damage and its mechanism]. Journal of Qingdao University Medical College. 2006;42:90–94.
42. Zhang Y, Li Y, Zheng F. [Effects of iron deficiency on blood lipids and liver lipid peroxidation in rats]. Chinese Chronic Disease Prevention and Control. 2011;19:577–78.
43. Batool M, Asad M, Lodhi GM, Shafqat A, Anis R, Kazmi AZ. Iron Deficiency Anemia; Challenges the Diagnostic and Prognostic Efficacy of HBA1c in Diabetes Mellitus. Pak Armed Forces Med J 2021;71(6):1967-1970.
44. Ooi SL, Pak SC, Campbell R, Manoharan A. Polyphenol-Rich Ginger (Zingiber officinale) for Iron Deficiency Anaemia and Other Clinical Entities Associated with Altered Iron Metabolism. Molecules. 2022 Sep 28;27(19):6417.
45. Chibanda Y, Brookes M, Churchill D, Al-Hassi H. The Ferritin, Hepcidin and Cytokines Link in the Diagnoses of Iron Deficiency Anaemia during Pregnancy: A Review. IJMS. 2023 Aug 28;24(17):13323.
46. Batista-da-Silva B, da Silva Garrote-Filho M, Santos HO, Knychala MA, Luz SY, Marques Rodrigues MO, et al. Decreased plasma iron levels in women with hyperglycemia are associated with inflammatory status and involve increased HbA1c, osmotic stability, and volume variability of red blood cells. Clinical Nutrition ESPEN. 2023 Jun;55:221-9