Why Iron Deficiency Is Still Massively Undertreated- And How to Fix It

You're exhausted, your brain feels foggy, your hair is shedding, you’re craving ice or even dirt, and you're dragging through the day with shortness of breath with even the simplest of activity. Sound familiar? For millions of people, especially women and girls, the culprit is iron deficiency and it's far more common than most doctors catch in the U.S.

Nearly 40% of girls and young women, ages 12 to 21, in a 2023 JAMA study had iron deficiency. Even more striking, over a quarter of them hadn't even started their periods and about 6% already had full blown iron deficiency anemia. The problem doesn't stop there. A 2024 study in Blood Advances looked at over 13,000 adults diagnosed with low iron in a major Minnesota health system. For the ones treated, it took a median of almost two years to regulate and over half still had low ferritin three years later. So, what we are seeing here is a large number of patients are walking around undiagnosed and once we identify them, we are undertreating.

How does the U.S. measure up against the rest of the world when comparing these stats? Europe tells a similar story in a study across five countries finding 27% of healthy adults over 70 are iron deficient, rising to 36% in those 80 and older. Another review showed that 40-55% of European women of reproductive age have low or depleted iron stores, with numbers skyrocketing in pregnancy if they don't supplement. That’s half of the studied population of women during one of the most important times of their life!

Why is this so underdiagnosed? What are some of the barriers to treatment? After practicing for over 20 years, I believe it’s largely due to problems with testing and effective affordable treatments. Us providers are not routinely checking the right tests. The symptoms are also vague and don’t always scream out iron deficiency. Standard blood work checks hemoglobin, which misses the majority of cases. So, if you apply the studies’ numbers to our everyday medical practice routines, we are missing it.

As primary care providers, we have to start doing better. As a provider focused on improving mine as well as my patients’ longevity, this is one piece of a strategic puzzle. Ferritin’s job is improving iron storage, fueling hemoglobin that results in contributing oxygen delivery to all tissues and reducing overall fatigue. We have to be able to effectively and affordably treat this fundamental condition.

How are we going to fix it? If you have fatigue symptoms but yet all the tests your provider have done still read as normal, ask them to do a cheap and simple ferritin level. Ferritin below 25 to 30 usually signals deficiency. A sweet spot for your level may feel best around 80-100.

If you are deficient, you need an effective affordable treatment protocol you can remain compliant with. You need to eat iron-rich foods every day, boost hydrochloric stomach acid during meals, and pair your iron rich foods with vitamin C to boost absorption. You need to avoid calcium rich foods at the same time as it can inhibit the absorption of iron. Time your coffee intake to be between meals due to it also blocking iron.

When considering supplementation, sometimes oral ones are hard on your stomach. Oral iron pills or liposomal drops can cause stomach issues like nausea and constipation, so many patients tend to quit prematurely. Over the past 10 years I have tried iron patches with my patients however, I remain skeptical and studies have found they don’t raise ferritin levels at all. In this case, talk to your primary care provider about gentle alternatives. One you could include is intravenous iron which can dramatically improve levels faster. IV iron works and is better, but insurance often fights it. If you are without insurance, we're talking around $3,000 for a hospital outpatient treatment. This just isn’t acceptable to most patients’ pocketbooks, and it is why our clinic has looked at providing more affordable IV iron options.

While you are treating, you need to also start investigating the root cause. Heavy periods, pregnancy, and specific gut issues deserve attention. Iron deficiency can be a slow onset, but it is not a minor inconvenience in one’s life. It affects energy, mood, exercise tolerance, even heart health, and ultimately organ health.

In the end, the good news is that iron deficiency is treatable. The first step is knowing what to look for. If you're sick and tired of being sick and tired, even if routine labs look normal, make sure to check your ferritin levels. You might finally get the answer you've been waiting for. Consult with one of our clinic providers to help you go in the right direction with finding the source, guiding diet, and supplementation that fits your needs. We can guide you with a therapy that is safe, affordable and effective, even to those without insurance.

Stahl-Gugger, A., Molino, C. D. G. R. C., Wieczorek, M., Chocano-Bedoya, P. O., Abderhalden, L. A., Schaer, D. J., … Bischoff-Ferrari, H. A. (2022). Prevalence and incidence of iron deficiency in European community-dwelling older adults: An observational analysis of the DO-HEALTH trial. Aging Clinical and Experimental Research, 34(9), 2205–2215. https://doi.org/10.1007/s40520-022-02093-0

Milman, N., Taylor, C. L., Merkel, J., & Brannon, P. M. (2017). Iron status in pregnant women and women of reproductive age in Europe. The American Journal of Clinical Nutrition, 106(Suppl 6), 1655S–1662S. https://doi.org/10.3945/ajcn.117.156000

Levi, M., Pedersen, O. B., Sørensen, H. T., Pedersen, L., Hallas, J., Brændgaard, A., … Johnsen, S. P. (2016). Epidemiology of iron deficiency anaemia in four European countries: A population-based study in primary care. European Journal of Haematology, 97(6), 583–593. https://doi.org/10.1111/ejh.12776

Weyand, A. C., Chaitoff, A., Freed, G. L., Sholzberg, M., Choi, S. W., & McGann, P. T. (2023). Prevalence of iron deficiency and iron-deficiency anemia in US females aged 12-21 years, 2003-2020. JAMA, 329(24), 2191–2193. https://doi.org/10.1001/jama.2023.8020