More Ontarians will be flagged for iron deficiency after doctors advocate for change to guidelines

Ontario could soon see more residents receiving treatment for iron deficiency thanks to new guidelines lowering the threshold for abnormal iron levels in the blood.

“Around the world, there's been substantial variation in what is defined as the lower limit of normal,” said Michelle Sholzberg, the director of hematology at the University of Toronto and the Hemequity lab at St. Michael's Hospital. 

“People who've had true iron deficiency have not been flagged as having iron deficiency because it hasn't been flagged as abnormal and now it will be flagged… and it will prompt clinician action.”

Lower limits previously flagged by some labs ranged from under five to under 15 micrograms per litre of ferritin, a blood protein that stores iron.

“The reason why that's problematic is because there's a lot of really great robust scientific evidence going as far back as 1992 suggesting that a level in adults below 30, and in pediatric patients below 20, is in fact in keeping with iron deficiency,” Sholzberg told CP24.com.

These levels will now be the ones clinicians are able to use when treating a patient for iron deficiency.

“We know that when levels are lower than 30 in adults, lower than 20 in kids, that's associated with negative stuff, including anemia, risk of blood transfusion, decreased cognition, energy levels, exercise tolerance, mood disorders,” she said.

“It’s going to be incredibly validating for patients because patients who have been told, ‘Oh no, you're not anemic so iron deficiency isn't a problem for you,’ which happens a lot of the time, will no longer be told that.”

Sholzberg is one of a number of health-care professionals who have spent years working with laboratories and other stakeholders to bring about this change.

The Hemequity lab also launched Raise the Bar, a website that offers resources for health-care providers on iron deficiency.

“There's people who came to the table and we've met multiple times per month for four and a half years. There's so many awesome people. I would love to see leadership from other laboratories in the community and hospital labs,” she said.

“What really made this happen is that we met on the regular and everybody was engaged and we all worked together.”

In a memo sent out earlier this month, Ontario Health called the change an “important first step” in boosting detection of iron deficiency in the province.

“This change is informed by the best available scientific evidence and will facilitate detection of iron deficiency. Iron deficiency is the most common micronutrient deficiency and is the number one cause of anemia worldwide; its detection and treatment has been declared a global priority by the World Health Organization,” the memo read.

“Non-anemic iron deficiency and iron deficiency anemia are associated with both morbidity and mortality especially in females of reproductive age.”

Sholzberg said it is estimated that about 40 per cent of women and girls, or people with the biological capacity for reproduction, have iron deficiency in the province.

“The most common cause of iron deficiency amongst women of reproductive age is heavy menstrual bleeding. There are estimates that up to 50 to 60 per cent of people who menstruate have heavy menstrual bleeding but don't know it,” she said.

“People who have true heavy menstrual bleeding when asked about their menstrual cycles, they describe them as normal.”

Standardizing the baseline measurement across laboratories will “level the playing field,” allowing for more equitable care, she said, noting that marginalized groups and those of lower socioeconomic status are at greater risk for iron deficiency because of decreased access to health care.

She said the changes have already been in effect at AlphaLabs for some time but will now be implemented at both LifeLabs and Dynacare.

She said the new guidelines may have a positive impact in other provinces.

“LifeLabs and Dynacare have a really big presence across the provinces and territories so this is really like a national change, which is amazing,” she said.

“And we want more labs to follow suit. We're hoping that this is just going lead to a bigger cascade of change.”