Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics

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Mukhyaprana Prabhu" }, { "@type": "Person", "name": "Ajit Singh" }, { "@type": "Person", "name": "Weena Stanley" }, { "@type": "Person", "name": "Gly Hb and Iron deficiency study group" } ], "publisher": { "@type": "Organization", "name": "F1000Research", "logo": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 480, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://f1000research.com/img/AMP/F1000Research_image.png", "height": 1200, "width": 150 }, "description": " Background Glycated hemoglobin (HbA1C) is a valuable marker in the management of Diabetes Mellitus, aiding in screening and diagnosis, and as a predictor of complications. Iron deficiency anaemia in developing countries has been found to affect the blood levels of HbA1C, decreasing its sensitivity. This study was undertaken to analyse the influence of iron deficiency anaemia on HbA1c levels, and thereby assess the reliability of A1C as a diagnostic marker for diabetes mellitus in iron deficient patients Methods This cross-sectional observational case-control study was conducted in a single tertiary care center. A total of 164 patients were recruited, 82 each from the case and control groups. The groups were matched for age and sex. Cases were nondiabetics with iron deficiency, and controls were nondiabetics without iron deficiency Results Age and sex were matched between cases and controls. The median ferritin levels were 5.9 ng/dl (n= 82) and 144 ng/dl (n= 82) among cases and controls. Transferrin saturation was distributed among cases, with a median of 3.4% for males (n= 36) and 3.2% for females (n= 46). Median hemoglobin levels were compared among each age group, with more severe anemia being seen as age increased. HbA1C was also compared age -wise, with results being statistically significant across each category. There was a statistically significant difference between HbA1C levels in cases and controls (p<0.0001), with some cases having A1C in the diabetic range, without any signs and symptoms of diabetes, and normal fasting and post prandial glucose Conclusion The results of our study suggest that although HbA1C is a diagnostic marker for type 2 diabetes mellitus, it loses its reliability when there is a co-existing iron deficiency anaemia. Hence certain amount of vigilance is mandated to confirm diabetes mellitus based on HbA1C, when the patient also has iron deficiency. 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F1000Research 2025, 14 :224 ( https://doi.org/10.12688/f1000research.160591.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] Shashikala Taggarshe Surkunda 1 , Aravind Sarvepalli 1 , M. Mukhyaprana Prabhu https://orcid.org/0000-0003-0679-3323 1 , Ajit Singh https://orcid.org/0000-0001-5767-6384 1 , Weena Stanley https://orcid.org/0000-0001-9266-8929 1 , Gly Hb and Iron deficiency study group Shashikala Taggarshe Surkunda 1 , Aravind Sarvepalli 1 , [...] M. Mukhyaprana Prabhu https://orcid.org/0000-0003-0679-3323 1 , Ajit Singh https://orcid.org/0000-0001-5767-6384 1 , Weena Stanley https://orcid.org/0000-0001-9266-8929 1 , Gly Hb and Iron deficiency study group PUBLISHED 20 Feb 2025 Author details Author details 1 Department of Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India Shashikala Taggarshe Surkunda Roles: Formal Analysis, Software, Writing – Original Draft Preparation, Writing – Review & Editing Aravind Sarvepalli Roles: Conceptualization, Data Curation, Investigation, Methodology M. Mukhyaprana Prabhu Roles: Conceptualization, Methodology, Supervision, Validation Ajit Singh Roles: Data Curation, Formal Analysis, Software, Writing – Review & Editing Weena Stanley Roles: Conceptualization, Data Curation, Formal Analysis, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Manipal Academy of Higher Education gateway. Abstract Background Glycated hemoglobin (HbA1C) is a valuable marker in the management of Diabetes Mellitus, aiding in screening and diagnosis, and as a predictor of complications. Iron deficiency anaemia in developing countries has been found to affect the blood levels of HbA1C, decreasing its sensitivity. This study was undertaken to analyse the influence of iron deficiency anaemia on HbA1c levels, and thereby assess the reliability of A1C as a diagnostic marker for diabetes mellitus in iron deficient patients Methods This cross-sectional observational case-control study was conducted in a single tertiary care center. A total of 164 patients were recruited, 82 each from the case and control groups. The groups were matched for age and sex. Cases were nondiabetics with iron deficiency, and controls were nondiabetics without iron deficiency Results Age and sex were matched between cases and controls. The median ferritin levels were 5.9 ng/dl (n= 82) and 144 ng/dl (n= 82) among cases and controls. Transferrin saturation was distributed among cases, with a median of 3.4% for males (n= 36) and 3.2% for females (n= 46). Median hemoglobin levels were compared among each age group, with more severe anemia being seen as age increased. HbA1C was also compared age -wise, with results being statistically significant across each category. There was a statistically significant difference between HbA1C levels in cases and controls (p<0.0001), with some cases having A1C in the diabetic range, without any signs and symptoms of diabetes, and normal fasting and post prandial glucose Conclusion The results of our study suggest that although HbA1C is a diagnostic marker for type 2 diabetes mellitus, it loses its reliability when there is a co-existing iron deficiency anaemia. Hence certain amount of vigilance is mandated to confirm diabetes mellitus based on HbA1C, when the patient also has iron deficiency. READ ALL READ LESS Keywords Anaemia, Iron deficiency, Glycated haemoglobin, Plasma glucose, Diabetes Corresponding Author(s) Weena Stanley ( [email protected] ) Close Corresponding author: Weena Stanley Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Taggarshe Surkunda S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Taggarshe Surkunda S, Sarvepalli A, Prabhu MM et al. Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :224 ( https://doi.org/10.12688/f1000research.160591.1 ) First published: 20 Feb 2025, 14 :224 ( https://doi.org/10.12688/f1000research.160591.1 ) Latest published: 20 Feb 2025, 14 :224 ( https://doi.org/10.12688/f1000research.160591.1 ) Introduction The glycosylated hemoglobin (HbA1c) assay is used worldwide as a point of care test to diagnose diabetes and to predict diabetic complications. 1 – 3 It is formed by an enzymatic glycation reaction between glucose and the amino group of the terminal valine in the beta chain of adult hemoglobin. The amount of HbA1c in a particular individual depends mainly on the glucose levels and is also postulated to depend on red cell life span, ethnicity, oxidative stress, type of hemoglobin and the principles or methods used to determine its levels in blood. 4 – 9 Iron deficiency anaemia (IDA) is one of the most common causes of nutritional anaemia. Diabetics are at increased risk of iron deficiency due to chronic inflammatory states, diabetic kidney disease and as a complication of gastrointestinal bleeding induced by antiplatelets which are commonly prescribed in these group of patients for various indications. 10 Iron deficiency increases HbA1c levels independent of glucose levels by increasing red cell life span along with decreasing hemoglobin concentration causing an increase in the proportion of glycated hemoglobin. Additionally, iron deficiency induced oxidative stress may further enhance hemoglobin glycation. 4 , 11 , 12 As diabetes and iron deficiency can both affect HbA1c levels, we attempted to study the influence of iron deficiency on HbA1c levels in the absence of diabetes mellitus. Methods This cross-sectional observational study was conducted at the Kasturba Hospital Manipal, India. Subjects for the study were sourced from the medical records of KMC Manipal, after clearance from the institutional ethics council who were admitted as in patients of the Department of Medicine over the three years from August 2018 to August 2021. Data were collected and analyzed during the study period as stipulated by the IEC. Eighty-two nondiabetic patients with iron deficiency were identified as cases and 82 nondiabetic patients without iron deficiency were identified as controls. The population in both the groups were matched for age and sex. Inclusion and exclusion criteria The cases consisted of nondiabetic and anaemic patients with hemoglobin levels<13 g/dl in men and < 12 g/dl in women. The serum ferritin of the patient population was <15 ng/dl. Fating plasma glucose <100 mg/dl OR 2-hour post prandial glucose <140 mg/dl OR random glucose <200 mg/dl without any of the symptoms of hyperglycemia. Controls consisted of patients without diabetes, prediabetes or impaired glucose tolerance who had no iron deficiency anemia. Patients with haemolytic anemia, chronic kidney disease, chronic liver disease, acute blood loss, recent blood transfusions within the last three months, pregnancy, chronic alcoholism, or malignancy were excluded from the study. These cases are excluded since they could interfere with the HbA1c values. Statistics All statistical calculations were performed using the Statistical Package for the Social Science 21.0 version (SPSS Inc., Chicago, IL, USA) for Microsoft Windows. Data are described in terms of range, mean ±standard deviation (± SD), median (IQR), frequencies (number of cases) and relative frequencies (percentages) as appropriate. Since the HbA1C distribution was skewed, the Mann-Whitney test was performed to compare the HbA1C of both groups. Spearman’s correlation coefficient was used to determine the correlation between hemoglobin and HbA1C. Chi square (χ 2 ) tests were performed to compare the categorical data. We used fisher’s exact test was used when the expected frequency was less than 5. A p value (probability value) below 0.05 was considered to be statistically significant. Results Age and sex were matched for cases and controls. The median ferritin levels were 5.9 ng/dl (n=82) and 144 ng/dl (n=82) among controls. Transferrin saturation was distributed among cases, with a median of 3.4% for males (n=35) and 3.2% for females (n=45) ( Table 1 ). Table 1. Baseline characteristics of study participants in case & control group. CASES (n,82) CONTROLS (n,82) P VALUE Age (years) 46 46 -- Sex (M:F) 1:1.3 1:1.3 -- Haemoglobin (g/dL) 6.6 13.7 0.001 Males 6.2 13.9 0.001 Females 7 12.9 0.001 Ferritin (ng/dL) 5.9 135 0.001 T-sat (%) 3.3 -- -- TIBC 429.5 RBS (mg/dL) 106 102 0.711 HbA1C (%) 5.6 5.3 0.001 Males 5.7 5.3 0.001 Females 5.6 5.2 0.001 Median hemoglobin levels were compared among each age group, with more severe anemia being seen as age increased (7.7 g/dL and 13.7 g/dL for cases and controls in the 20-44 year category; 6.2 g/dL and 13.65 g/dL for cases and controls in the 45-64 year category; 5.6 g/dL and 13.85 g/dL for cases and controls in the ≥65 year category). HbA1C was also compared age wise, with results being statistically significant across each category as well (median A1C in the 20-44 year category being 5.4% for cases vs 5.2% for controls, n=36, p≤0.0001; for the 45-64 year category being 5.75% for cases vs 5.3% for controls, n= 30, p≤0.0001; and in the ≥65 year category having 6.3% for cases vs 5.5% for controls, n=16, p=0.0003) ( Figure 1 & Figure 2 ). Figure 1. Age wise comparison of HbA1C among cases and controls. Figure 2. Age wise comparison of HbA1c in both the genders among cases and controls. In our study patients with anemia and iron deficiency showed a statistically significant negative correlation between HbA1c and haemoglobin levels (Spearman’s correlation coefficient (-0.285) (p=0.009)). Gender wise, there was a statistically negative correlation between HbA1C and hemoglobin in males (spearman’s correlation coefficient (-0.346) (p=0.039)) whereas in females there was a negative correlation but it was not statistically significant (Spearman’s correlation coefficient (-0.210) (p=0.161)). There was negative but not statistically significant correlation observed between HbA1c level and and serum ferritin level (n=82) (Spearman’s correlation coefficient (-0.050) (p=0.659)), HbA1C and serum iron (n=80) (Spearman’s correlation coefficient (-0.073) (p= 0.52)), HbA1C and transferrin saturation (n=80) (Spearman’s correlation coefficient (-0.105) (p=0.353)) and positive but not statistically significant correlation between HbA1c and TIBC (n=80) (Spearman’s correlation coefficient (0.132) (p=0.242)). Discussion HbA1c alone, if taken as a marker of diabetes in a patient with iron deficiency and asymptomatic diabetes, will result in a false diagnosis of diabetes and complications related to antidiabetic therapy. Several studies have stressed the futility of diagnosing diabetes based on HbA1C alone as a marker of diabetes severity in an iron deficient population. HbA1C shows a linear relationship with red blood cell life span (cohen et al), which is inversely proportional to the mean cell haemoglobin (MCH) in patients with anemia due to iron deficiency as found in a study conducted by Koga et al., where women in the pre-menopausal age group with low MCH had higher HbA1c levels independent of plasma glucose levels. 11 , 13 This explains the negative correlation between haemoglobin and HbA1c found in our study and is consistent with studies conducted by Madhu et al., Silva et al and Rajagopal et al. 14 – 16 These findings provide additional support to the notion that iron deficiency elevates HbA1c levels. Grossman et al. 17 found no correlation between hemoglobin and HbA1c levels suggesting that HbA1c levels in nondiabetic elderly individuals may be interpreted independently of hemoglobin or nutritional anaemia factors. However, their study categorized patients based on HbA1c and assessed haemoglobin levels while our study and others (Madhu et al., Silva et al and Rajagopal et al) adopted the opposite approach. This difference in study design might have contributed to confounding results. A large retrospective study conducted by Rao et al. 18 not only showed a statistically significant difference in HbA1c levels in subjects with iron deficiency and normal individuals but also in both males (6% versus 5.6%) and females (5.7% versus 5.4%). These findings were similar to those of the present study. Differences in HbA1c levels among subjects in the study group with and without iron deficiency were observed irrespective of the method employed to assess HbA1c levels in various studies. Silva et al. 15 have done a head-to-head comparison between ion exchange HPLC and immunoturbidimetry and found that in both the methods HbA1c was considerably higher in patients with iron deficiency than without iron deficiency ( Table 2 ). Table 2. Comparison of characteristics in cases with reference studies. Present Study J.F. Silva et al 15 S.V. Madhu et al 14 L.V. Rao et al 20 Rajgopal et al 16 Year of publication -- 2016 2017 2022 2017 Sample size 164 122 122 33,760 150 Iron deficiency anemia (n) 82 61 62 12,320 75 Age (years) 46 46 Cases 48 ± 14 31.4 ± 11.3 -- 45.1 controls 49 ± 14 32.5 ± 10.1 -- Haemoglobin (g/dL) cases 6.6 9.4 ± 1.9 7.39 ± 1.22 -- 11.5 Ferritin (ng/dL) cases 5.9 5.8 (1.1–14.0) 17.3 ± 3.0 -- 12.1 HbA1C (%) Cases 5.6 5.6 ± 0.4, 5.7 ± 0.4 5.5 ± 0.7 6 6.84 Controls 5.3 5.3 ± 0.4, 5.3 ± 0.3 4.9 ± 0.5 5.6 5.12 In a study conducted by Christy et al., 19 subjects with diabetes and well-controlled sugar levels and iron deficiency exhibited significantly higher HbA1c levels than iron-sufficient diabetic individuals, corroborating our finding that iron deficiency anaemia independently influences HbA1c levels. In contrast, Solomon et al., 20 found significantly lower HbA1c levels (6.18 ± 1.57) in the IDA group than in the control group (7.74 ± 1.81) (p < 0.05) within a diabetic population. However, it is worth noting that this study did not standardize blood sugar levels using fasting, random, postprandial blood glucose levels, or oral glucose tolerance tests. It must be emphasized that in the present study, random blood sugar levels were comparable between both the study groups with median RBS values of 106 mg/dL and 102 mg/dL among cases and controls, respectively. A difference was observed in the HbA1c levels. The highest HbA1c level was 8.6% noted for a 40-year-old gentleman with anal fissures with a haemoglobin of 3.8 g/dL. His RBS at admission was 89 mg/dL and FPG was 84 mg/dL. Ferritin was 4.5 ng/mL. 19.5% of cases had A1C in the diabetic range despite nondiabetic range plasma sugars. None of the patients had started receiving antidiabetic drugs. Lyons et al., 21 in a study of non-diabetic individuals from the RODAM study group, found a significant association between iron deficiency and increased odds of having HbA1c levels in the prediabetes range (5.5-6.5%) compared to women without iron deficiency (OR: 1.43, p<0.01). This aligns with our findings of higher median HbA1c levels in women with iron deficiency anaemia (5.6%) than in those without (5.2%). However, the study did not identify a similar association between iron deficiency and HbA1c levels in men, contradicting our findings. The results of the present study showed a higher median HbA1c in men with iron deficiency anaemia (5.7%) than in those without (5.2%). This discrepancy may be attributed to the smaller sample size of male patients with and without iron deficiency (n/n’=68/1177) in the study by Lyons et al. In a large-scale study conducted by Ford et al., 22 where both diabetic and non-diabetic patients were categorized into four groups according to their haemoglobin and iron indices, and proposed that in a population, IDA has negligible effect on HbA1c levels or on diabetes prevalence which contradicts our observation. However, the same study also reported higher glycosylated hemoglobin values in individuals with iron deficiency than in those with normal iron status, suggesting that the results of this study might not be applicable to patients with severe IDA. Correction of iron deficiency results in an increase in the young erythrocyte population with a decrease in the proportion of glycated haemoglobin levels, as observed in studies done in both diabetic and nondiabetic iron deficient individuals. 14 , 23 Aydin et al. 24 studied diabetic iron deficient individuals and showed a significant statistical decline in the mean HbA1c from 7.09 ± 0.51(%) to 6.69 ± 0.53 (%) with the rise in haemoglobin levels (Spearman rho = −0.362; p < 0.001), and with similar baseline FBS levels before 118 (mg/dL) (108–132) mg/dL and after iron therapy 116 (mg/dL) (106–125). Similar observations were found in a study 25 where iron therapy led to a statistically significant decline in HbA1c levels before (5.01 ± 0.39) and post-iron (4.69 ± 0.38) therapy in nondiabetic iron deficient pregnant women. The results of these independent investigations corroborate our findings regarding the relationship between IDA and HbA1c levels. In contrast, a study by Sinha et al. 26 involving nondiabetic iron deficiency anemia observed increased HbA1c levels following iron therapy. However, the small sample size and potential confounding factors may have influenced the results. Another study from southern India by Kalasker et al. 27 reported that among their 40 non-diabetic test subjects with iron deficiency, the mean HbA1c was lower (5.91%) compared to their control group peers (6.54%). These findings contradict our study, which may be due to the higher mean hemoglobin level in their cases (8.74 ± 1.98 g/dL) compared to the cases in our study (6.6 g/dL, range 4.9–9 g/dL). The lower hemoglobin levels in our study likely indicate more severe anemia and greater red blood cell turnover, which may have contributed to the observed differences in HbA1c levels. Iron deficiency induces oxidative stress, resulting in increased malonaldehyde, which accelerates glycation of haemoglobin. The same concept was reinforced by a study conducted by Ghazy et al., who showed a decrease in glycated haemoglobin and malonaldehyde accompanied by correction of iron deficiency in nondiabetic patients, which reinforces our finding of a positive correlation between iron deficiency and HbA1c. 9 , 28 Our study’s strengths include a substantial sample size and careful matching of participants based on age and sex. A limitation of our study was the inability to examine the impact of treating iron deficiency anemia on HbA1c levels. Conclusion The findings of our study emphasize the importance of carefully interpreting HbA1c levels in individuals with iron deficiency, especially in areas with a high anemia prevalence, to avoid misdiagnosing diabetes or prediabetes. Moreover, the substantial prevalence of iron deficiency among patients with diabetes underscores the potential unreliability of HbA1c as the sole indicator of glycaemic control. Inaccurate assessment of glycaemic status through HbA1c in diabetics who also have iron deficiency anaemia that is co-existing may lead to unnecessary escalation of antidiabetic treatments, additional financial burden, and, most importantly, dangerous complications of hypoglycemia. Ethics and consent This study was approved by the review board of our institution -Kasturba Medical College and Kasturba Hospital ethics committee on 2 nd June 2021 (Reference number- IEC 200/2021). Written consent was taken from all participants Data were collected from the hospital’s medical records, and patient confidentiality was protected. Data availability Figshare: Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabeticsd Item. https://doi.org/10.6084/m9.figshare.28124336.v1 . 29 This project contains the following underlying data: • EXCEL SHEET Gly Hb IDA study Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). 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Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India Shashikala Taggarshe Surkunda Roles: Formal Analysis, Software, Writing – Original Draft Preparation, Writing – Review & Editing Aravind Sarvepalli Roles: Conceptualization, Data Curation, Investigation, Methodology M. Mukhyaprana Prabhu Roles: Conceptualization, Methodology, Supervision, Validation Ajit Singh Roles: Data Curation, Formal Analysis, Software, Writing – Review & Editing Weena Stanley Roles: Conceptualization, Data Curation, Formal Analysis, Project Administration, Resources, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 20 Feb 2025, 14:224 https://doi.org/10.12688/f1000research.160591.1 Copyright © 2025 Taggarshe Surkunda S et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Taggarshe Surkunda S, Sarvepalli A, Prabhu MM et al. Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :224 ( https://doi.org/10.12688/f1000research.160591.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 20 Feb 2025 Views 0 Cite How to cite this report: Tozzo V. Reviewer Report For: Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :224 ( https://doi.org/10.5256/f1000research.176507.r423024 ) The direct URL for this report is: https://f1000research.com/articles/14-224/v1#referee-response-423024 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 24 Nov 2025 Veronica Tozzo , UCLA, California, USA Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.176507.r423024 This cross-sectional case–control study recruited 164 non-diabetic adults, 82 with iron deficiency anemia (IDA) and 82 without, to evaluate the effects of IDA on HbA1c levels. Despite comparable random glucose values, individuals with IDA showed significantly higher median HbA1c ... Continue reading READ ALL This cross-sectional case–control study recruited 164 non-diabetic adults, 82 with iron deficiency anemia (IDA) and 82 without, to evaluate the effects of IDA on HbA1c levels. Despite comparable random glucose values, individuals with IDA showed significantly higher median HbA1c across all age groups, and hemoglobin levels were negatively correlated with HbA1c. The authors conclude that HbA1c may be an unreliable diagnostic marker for diabetes in the presence of iron deficiency and emphasize caution when interpreting elevated HbA1c in anemic patients. Specific comments: 1) The manuscript does not describe how the authors executed the exclusion for haemolytic anemia, chronic kidney disease, chronic liver disease, acute blood loss, recent blood transfusions within the last three months, pregnancy, chronic alcoholism, or malignancy. It is unclear whether diagnoses were based solely on laboratory values, specific ICD codes extracted from records, or clinician documentation. Clarifying the exact method used to identify and verify eligible subjects is important for reproducibility of the findings. 2) Table 1 and much of the results section report only medians or single values without corresponding measures of dispersion such as standard deviations or interquartile ranges. This omission makes it difficult to evaluate the underlying variability or to assess whether the reported p-values reflect clinically meaningful differences. 3) The overall conclusion that iron deficiency anemia can raise HbA1c independent of glycemia has been demonstrated repeatedly in larger and more rigorous studies, several of which the authors cite in their discussion. Given this substantial existing evidence base, the contribution of the present study to the literature is unclear. The authors should articulate what new insight this study adds beyond confirming well-established relationships or otherwise contextualize its incremental value. 4) The authors don't discuss the striking differences and increase (for both cases and controls) across age groups. 5) The overall writing of the papers and level of details could be improved. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Red blood cell lifespan effects on hemoglobin A1c, hematology, machine learning, computational biomedicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tozzo V. Reviewer Report For: Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :224 ( https://doi.org/10.5256/f1000research.176507.r423024 ) The direct URL for this report is: https://f1000research.com/articles/14-224/v1#referee-response-423024 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 20 Feb 25 read Veronica Tozzo , UCLA, California, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Tozzo V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 24 Nov 2025 | for Version 1 Veronica Tozzo , UCLA, California, USA 0 Views copyright © 2025 Tozzo V. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This cross-sectional case–control study recruited 164 non-diabetic adults, 82 with iron deficiency anemia (IDA) and 82 without, to evaluate the effects of IDA on HbA1c levels. Despite comparable random glucose values, individuals with IDA showed significantly higher median HbA1c across all age groups, and hemoglobin levels were negatively correlated with HbA1c. The authors conclude that HbA1c may be an unreliable diagnostic marker for diabetes in the presence of iron deficiency and emphasize caution when interpreting elevated HbA1c in anemic patients. Specific comments: 1) The manuscript does not describe how the authors executed the exclusion for haemolytic anemia, chronic kidney disease, chronic liver disease, acute blood loss, recent blood transfusions within the last three months, pregnancy, chronic alcoholism, or malignancy. It is unclear whether diagnoses were based solely on laboratory values, specific ICD codes extracted from records, or clinician documentation. Clarifying the exact method used to identify and verify eligible subjects is important for reproducibility of the findings. 2) Table 1 and much of the results section report only medians or single values without corresponding measures of dispersion such as standard deviations or interquartile ranges. This omission makes it difficult to evaluate the underlying variability or to assess whether the reported p-values reflect clinically meaningful differences. 3) The overall conclusion that iron deficiency anemia can raise HbA1c independent of glycemia has been demonstrated repeatedly in larger and more rigorous studies, several of which the authors cite in their discussion. Given this substantial existing evidence base, the contribution of the present study to the literature is unclear. The authors should articulate what new insight this study adds beyond confirming well-established relationships or otherwise contextualize its incremental value. 4) The authors don't discuss the striking differences and increase (for both cases and controls) across age groups. 5) The overall writing of the papers and level of details could be improved. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? No Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Red blood cell lifespan effects on hemoglobin A1c, hematology, machine learning, computational biomedicine I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Tozzo V. Peer Review Report For: Influence of Iron Deficiency Anaemia on Glycated Haemoglobin in Non-diabetics [version 1; peer review: 1 not approved] . F1000Research 2025, 14 :224 ( https://doi.org/10.5256/f1000research.176507.r423024) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-224/v1#referee-response-423024 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions Adjust parameters to alter display View on desktop for interactive features Includes Interactive Elements View on desktop for interactive features Competing Interests Policy Provide sufficient details of any financial or non-financial competing interests to enable users to assess whether your comments might lead a reasonable person to question your impartiality. 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