Serum ferritin as an indicator of iron status: what do we need to know?

The relationship between menorrhagia, iron deficiency, and anaemia in recreationally active females: An exploratory population based screening study

OBJECTIVES

Iron deficiency, anaemia, and menorrhagia - or heavy menstrual bleeding - are interrelated conditions that are highly prevalent and commonly underrecognised in exercising females of reproductive age. This study utilised a screening tool to identify risk factors and symptoms associated with heavy menstrual bleeding, iron deficiency, and anaemia in this population.

DESIGN

An observational, cross sectional survey study was employed.

METHODS

1042 active females (aged 18-65) completed a comprehensive screening questionnaire and 887 (85 % compliance) provided a fingerprick blood sample for haemoglobin (Hb) concentration measurement. Women that presented as anaemic (defined as a [Hb] < 120 g/L) or deemed to be at risk of iron deficiency (120 < [Hb] < 130 g/L) were asked to complete follow-up blood tests to screen for iron studies.

RESULTS

Average [Hb] was 134.2 ± 12.1 g/L, with 94 individuals considered anaemic (10.6 %). Of the sample, 104 underwent follow-up blood tests; 51 (~49 %) presented with iron deficiency (defined as ferritin <30 μg/L). Based on survey responses, 274 (30.9 %) participants were determined to have heavy menstrual bleeding. Those presenting with heavy menstrual bleeding were younger, exercised fewer hours per week, and were more likely to have a history of iron deficiency or anaemia (all p < 0.05). Participants reporting a history of anaemia or iron deficiency were more likely to have heavy menstrual bleeding (anaemia: 39.7 %; iron deficiency; 36.9 %; both p < 0.05).

CONCLUSIONS

In this cohort of exercising females of reproductive age, the prevalence of anaemia was 10.6 %. There is a strong association between heavy menstrual bleeding and a self-reported history of iron deficiency and anaemia. Greater awareness of heavy menstrual bleeding and its relationship with iron deficiency and anaemia is needed in this population. Non-invasive screening should be conducted to raise awareness and further understand the associated risk factors and symptomatology.

Validation of an automated iron stain process for use with bone marrow aspirate smear slides

The assessment of bone marrow iron stores is typically performed on an aspirate smear slide that has been manually stained by a technologist using a commercially available kit. This approach can contribute to inconsistent results and limit the broad use of iron staining in bone marrow specimens, particularly when laboratories have low staffing and/or high specimen volumes. Here, we describe the adaptation and validation of the Ventana Benchmark automated stainer and iron stain kit for routine clinical use of staining iron in bone marrow aspirate smear slides. We assessed accuracy and precision of the Ventana automated iron staining protocol compared to the Perls Prussian blue manual iron staining index method. Hematopathologists assigned Gale scores and enumerated the percentages of erythroid sideroblasts on paired patient bone marrow aspirate smear slides stained by the automated method and the manual iron staining method. We found a similar level of performance of the Ventana automated iron stain relative to the index manual method (as assessed by Pearson correlation and Bland-Altman analyses). In addition, there was low imprecision between replicates performed via the automated iron stain protocol. We also report superior qualitative findings of the automated method in ease of localization of iron storage, visualization of sideroblasts, and counterstain consistency. Automated iron staining of bone marrow aspirate smear slides performed similarly to the manual method and may allow for accurate routine evaluation of bone marrow iron stores as part of bone marrow analysis.

Anemia in Pregnancy With CKD

Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.

Transferrin Saturation, Serum Ferritin, and C-Reactive Protein vs. Serum Ferritin for an optimal Iron Deficiency Diagnosis in Candidates for Bariatric Surgery

INTRODUCTION

Iron has different physiological processes and is regulated by hepcidin that is also an acute phase reactant, which increases with inflammation. Obesity produces a pro-inflammatory state, affecting directly the normal regulation of iron, causing ferritin (FER) deficiency. FER is used as the only indicator of the status of iron in patients with obesity, so the majority of them would be underdiagnosed, leading to a high prevalence of iron deficiency (ID) and anemia. The aim of this study is to evaluate the diagnostic tests: transferrin saturation (TS), FER, and C-reactive protein (CRP) vs. FER with the objective of analyzing the most accurate variable for the diagnosis of ID.

MATERIALS AND METHODS

We present a cross-sectional, analytical, and retrospective study, evaluating the diagnostic tests in 96 patients, to whom two methods were applied for the diagnosis of ID: method 1 (FER < 30 ng/mL) and method 2 divided into 2A (FER < 30 ng/mL), 2B (FER 30-100 ng/mL + CRP ≥ 5 mg/L), 2C (FER 100-300 ng/mL + CRP ≥ 5 mg/L + TS < 20%), and 2D (TS < 20%).

RESULTS

The prevalence of ID obtained using method 1 was 30.2% while 69.8% presented ID using total method 2, confirming an underdiagnosis of 39.6%.

CONCLUSION

The inflammatory state in patients with obesity must be considered in the diagnosis of ID. The use of TS, FER, and CRP has greater validity than the use of serum FER for the diagnosis of ID in patients with obesity.

Consumption of Iron-Fortified Lentils Is Protective against Declining Iron Status among Adolescent Girls in Bangladesh: Evidence from a Community-Based Double-Blind, Cluster-Randomized Controlled Trial

BACKGROUND

In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical.

OBJECTIVES

This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status.

METHODS

A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation.

RESULTS

Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 μg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 μg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 μg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 μg/L) compared with the usual intake group.

CONCLUSIONS

Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health.

TRIAL REGISTRATION NUMBER

This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734.

Iron deficiency anemia among women: An issue of health equity

Iron deficiency is the most common and widespread nutritional deficiency in the world. For women, the risk of iron deficiency and iron deficiency anemia increases due to iron demands during pregnancy and regular iron losses due to menstruation during reproductive years. These interrelated conditions are of public health concern as they are highly prevalent, and the negative consequences such as chronic fatigue, cognitive impairment and poor quality of life are broad and multifaceted. People of low socioeconomic status are at higher risk of iron deficiency due to low intake of expensive iron-rich foods, and decreased access to healthcare. In this review, we applied a health equity lens to describe the current state of care for women with iron deficiency with or without anemia. We have highlighted several structural challenges that span from the laboratory diagnosis, inconsistent screening guidelines, and stigma associated with heavy menstrual bleeding, to treatment barriers.

Value of serum iron and urine neutrophil gelatinase-associated lipocalin in predicting the mortality of critically ill patients with sepsis

INTRODUCTION

We aimed to investigate the association of iron metabolism-related parameters with 60-day mortality in critically ill patients with sepsis.

METHODS

Serum or urine concentrations of iron metabolism-related parameters on intensive care unit admission were measured in a prospective cohort of 133 eligible patients with sepsis according to the Sepsis-3 criteria, and these values were compared between survivors and nonsurvivors, categorized according to their 60-day survival status. Cox regression analyses were performed to examine the association between iron parameters and 60-day mortality. Kaplan-Meier methods were used to illustrate the differences in survival between different iron parameters.

RESULTS

Of the 133 patients included in the study, 61 (45.8%) had died by day 60. After adjusting for confounding variables, higher concentrations of serum iron (cut-off 9.5 μmol/mL) and higher concentrations of urine neutrophil gelatinase-associated lipocalin (uNGAL; cut-off 169.3 ng/mL) were associated with a significantly greater risk of death in the Cox regression analysis. These two biomarkers combined with Sequential Organ Failure Assessment (SOFA) scores increased the area under the receiver operating characteristic (AUROC) curve to 0.85.

DISCUSSION

These findings suggest that higher concentrations of serum iron and uNGAL are each associated with higher 60-day mortality, and they add significant accuracy to this prediction in combination with SOFA. Abbreviations: uNGAL: urine neutrophil gelatinase-associated lipocalin; ICU: intensive care unit; SOFA: Sequential Organ Failure Assessment; APACHE II: the Acute Physiology and Chronic Health Evaluation II; ELISA: enzyme-linked immunosorbent assay; HR: hazard ratio; CIs: confidence intervals; WBC: white blood cell; TBIL: total bilirubin.

Hemochromatosis: Ferroptosis, ROS, Gut Microbiome, and Clinical Challenges with Alcohol as Confounding Variable

Hemochromatosis represents clinically one of the most important genetic storage diseases of the liver caused by iron overload, which is to be differentiated from hepatic iron overload due to excessive iron release from erythrocytes in patients with genetic hemolytic disorders. This disorder is under recent mechanistic discussion regarding ferroptosis, reactive oxygen species (ROS), the gut microbiome, and alcohol abuse as a risk factor, which are all topics of this review article. Triggered by released intracellular free iron from ferritin via the autophagic process of ferritinophagy, ferroptosis is involved in hemochromatosis as a specific form of iron-dependent regulated cell death. This develops in the course of mitochondrial injury associated with additional iron accumulation, followed by excessive production of ROS and lipid peroxidation. A low fecal iron content during therapeutic iron depletion reduces colonic inflammation and oxidative stress. In clinical terms, iron is an essential trace element required for human health. Humans cannot synthesize iron and must take it up from iron-containing foods and beverages. Under physiological conditions, healthy individuals allow for iron homeostasis by restricting the extent of intestinal iron depending on realistic demand, avoiding uptake of iron in excess. For this condition, the human body has no chance to adequately compensate through removal. In patients with hemochromatosis, the molecular finetuning of intestinal iron uptake is set off due to mutations in the high-FE2+ (HFE) genes that lead to a lack of hepcidin or resistance on the part of ferroportin to hepcidin binding. This is the major mechanism for the increased iron stores in the body. Hepcidin is a liver-derived peptide, which impairs the release of iron from enterocytes and macrophages by interacting with ferroportin. As a result, iron accumulates in various organs including the liver, which is severely injured and causes the clinically important hemochromatosis. This diagnosis is difficult to establish due to uncharacteristic features. Among these are asthenia, joint pain, arthritis, chondrocalcinosis, diabetes mellitus, hypopituitarism, hypogonadotropic hypogonadism, and cardiopathy. Diagnosis is initially suspected by increased serum levels of ferritin, a non-specific parameter also elevated in inflammatory diseases that must be excluded to be on the safer diagnostic side. Diagnosis is facilitated if ferritin is combined with elevated fasting transferrin saturation, genetic testing, and family screening. Various diagnostic attempts were published as algorithms. However, none of these were based on evidence or quantitative results derived from scored key features as opposed to other known complex diseases. Among these are autoimmune hepatitis (AIH) or drug-induced liver injury (DILI). For both diseases, the scored diagnostic algorithms are used in line with artificial intelligence (AI) principles to ascertain the diagnosis. The first-line therapy of hemochromatosis involves regular and life-long phlebotomy to remove iron from the blood, which improves the prognosis and may prevent the development of end-stage liver disease such as cirrhosis and hepatocellular carcinoma. Liver transplantation is rarely performed, confined to acute liver failure. In conclusion, ferroptosis, ROS, the gut microbiome, and concomitant alcohol abuse play a major contributing role in the development and clinical course of genetic hemochromatosis, which requires early diagnosis and therapy initiation through phlebotomy as a first-line treatment.

Unraveling the Role of Maternal Serum Ferritin Levels in Preterm Delivery: A Comprehensive Review

Preterm delivery remains a critical global health concern, with numerous adverse consequences for both neonate and healthcare systems. Understanding the relationship between maternal ferritin levels, as a marker of iron status, and the risk of preterm birth is the focal point of this comprehensive review. We provide insights into the multifaceted nature of this connection, highlighting factors that influence maternal ferritin levels, including dietary intake, genetic and physiological variations, comorbidities, and iron supplementation. While evidence suggests an association between low maternal ferritin levels and preterm birth, causality remains elusive, necessitating further research with robust study designs. The potential mechanisms linking maternal iron status to preterm birth, such as inflammation, infection, and oxidative stress, are explored, underscoring the need for in-depth investigations. This comprehensive review emphasizes the clinical importance of assessing and monitoring maternal ferritin levels in prenatal care and advocates for public health initiatives to raise awareness and provide targeted interventions, particularly in high-risk populations. As we strive to address these unanswered questions and embark on innovative research directions, the aim is to ultimately enhance our understanding of the complex relationship between maternal iron status and preterm birth, leading to improved maternal and child health outcomes.

Molecular insights into placental iron transfer mechanisms and maternofetal regulation

PURPOSE

Adequate iron transportation from the mother across the placenta is crucial for fetal growth and establishing sufficient iron stores in neonates at birth. The past decade has marked significant discoveries in iron metabolism with the identification of new players and mechanisms. Immunohistochemical studies rendered valuable data on the localization of substantial iron transporters on placental syncytiotrophoblasts. However, the function and regulation of maternal-placentofetal iron transporters and iron handling is still elusive and requires more attention.

METHODS

A thorough literature review was conducted to gather information about placental iron transfer, the role of regulators and maintenance of iron homeostasis.

RESULTS

The role of classical and new players in maternal-fetal iron transport and the regulation in the placenta has been addressed in this review. Animal and human studies have been discussed. The role of placental iron regulation in thalassemia and hemochromatosis pregnancies has been reviewed.

CONCLUSIONS

The current advances that highlight the mechanisms of placental iron regulation and transport in response to maternal and fetal signals have been presented.

Use of iron in perinatal anaemia: Indications for women’s health care policies and procedure

This paper reviews management of obstetric anaemia and the role of intravenous iron for the treatment of obstetric anaemia. Red blood cell transfusions are routinely used for haemoglobin restoration in anaemic women. The decision for red blood cell transfusion is made on a combination of haemoglobin level and clinical status, and it is suggested that transfusions are not necessary in those who are well compensated or when alternative therapy is available. To reduce the risk, intravenous iron infusion is proposed as a bloodless therapeutic approach. There are a variety of iron preparations. Intravenous iron infusion can reduce the requirement for blood transfusion in hemodynamically stable women with perinatal anaemia, especially in resource-scarce settings. It a cost-effective bloodless approach for the treatment of anaemia than can enhance patient outcomes. According to the literature, when haemoglobin is greater than 90 g/L, blood transfusion is not often required. In perinatal women with anaemia, the decision whether to administer blood or iron is based on patient preferences, haemoglobin levels, clinical symptoms, past and present medical conditions and the clinician’s judgement. Nevertheless, due to the lack of rigid criteria for blood transfusions in the majority of clinical settings, it is considered the default treatment for anaemia in perinatal women.

Biology of Anemia: A Public Health Perspective

Our goal is to present recent progress in understanding the biological mechanisms underlying anemia from a public health perspective. We describe important advances in understanding common causes of anemia and their interactions, including iron deficiency (ID), lack of other micronutrients, infection, inflammation, and genetic conditions. ID develops if the iron circulating in the blood cannot provide the amounts required for red blood cell production and tissue needs. ID anemia develops as iron-limited red blood cell production fails to maintain the hemoglobin concentration above the threshold used to define anemia. Globally, absolute ID (absent or reduced body iron stores that do not meet the need for iron of an individual but may respond to iron supplementation) contributes to only a limited proportion of anemia. Functional ID (adequate or increased iron stores that cannot meet the need for iron because of the effects of infection or inflammation and does not respond to iron supplementation) is frequently responsible for anemia in low- and middle-income countries. Absolute and functional ID may coexist. We highlight continued improvement in understanding the roles of infections and inflammation in causing a large proportion of anemia. Deficiencies of nutrients other than iron are less common but important in some settings. The importance of genetic conditions as causes of anemia depends upon the specific inherited red blood cell abnormalities and their prevalence in the settings examined. From a public health perspective, each setting has a distinctive composition of components underlying the common causes of anemia. We emphasize the coincidence between regions with a high prevalence of anemia attributed to ID (both absolute and functional), those with endemic infections, and those with widespread genetic conditions affecting red blood cells, especially in sub-Saharan Africa and regions in Asia and Oceania.

Iron status in early infancy is associated with trajectories of cognitive development up to pre-school age in rural Gambia

INTRODUCTION

Iron deficiency is among the leading risk factors for poor cognitive development. However, interventions targeting iron deficiency have had mixed results on cognitive outcomes. This may be due to previous interventions focusing on the correction of iron deficiency anaemia in late infancy and early childhood, at which point long lasting neural impacts may already be established. We hypothesise that the relationship between iron status and cognitive development will be observable in the first months of life and will not be recovered by 5 years of age.

METHODS

Using data from the Brain Imaging for Global Health (BRIGHT) Study in Gambia (n = 179), we conducted mixed effects modelling to assess the relationship between iron status at 5 months of age and trajectories of cognitive development from 5 months- 5 years using (i) a standardised measure of cognitive development (Mullen Scales of Early Learning) and (ii) an eye-tracking assessment of attention processing (visual disengagement time).

RESULTS

All infants were iron sufficient at 1 month of age. At 5 and 12 months of age 30% and 55% of infants were iron deficient respectively. In fully adjusted analyses, infants in the lowest tercile of soluble transferrin receptor (sTfR) (best iron status) achieved MSEL Cognitive Scores on average 1.9 points higher than infants in the highest sTfR tercile (p = 0.009, effect size = 0.48). There was no evidence that this group difference was recovered by 5 years of age. Infants in the lowest sTfR tercile had visual disengagement time 57ms faster than the highest tercile (p = 0.001, effect size = 0.59). However, this difference diminished by early childhood (p = 0.024).

CONCLUSION

Infants are at risk of iron deficiency in early infancy. A relationship between iron status and cognitive development is apparent from 5 months of age and remains observable at 5 years of age. One mechanism by which iron availability in early infancy impacts brain development may be through effects on early attentional processing, which is rapidly developing and has substantial nutritional requirements during this period. To support neurocognitive development, prevention of iron deficiency in pre- and early postnatal life may be more effective than correcting iron deficiency once already established.

Oral Iron Absorption of Ferric Citrate Hydrate and Hepcidin-25 in Hemodialysis Patients: A Prospective, Multicenter, Observational Riona-Oral Iron Absorption Trial

Oral ferric citrate hydrate (FCH) is effective for iron deficiencies in hemodialysis patients; however, how iron balance in the body affects iron absorption in the intestinal tract remains unclear. This prospective observational study (Riona-Oral Iron Absorption Trial, R-OIAT, UMIN 000031406) was conducted at 42 hemodialysis centers in Japan, wherein 268 hemodialysis patients without inflammation were enrolled and treated with a fixed amount of FCH for 6 months. We assessed the predictive value of hepcidin-25 for iron absorption and iron shift between ferritin (FTN) and red blood cells (RBCs) following FCH therapy. Serum iron changes at 2 h (ΔFe2h) after FCH ingestion were evaluated as iron absorption. The primary outcome was the quantitative delineation of iron variables with respect to ΔFe2h, and the secondary outcome was the description of the predictors of the body's iron balance. Generalized estimating equations (GEEs) were used to identify the determinants of iron absorption during each phase of FCH treatment. ΔFe2h increased when hepcidin-25 and TSAT decreased (-0.459, -0.643 to -0.276, p = 0.000; -0.648, -1.099 to -0.197, p = 0.005, respectively) in GEEs. FTN increased when RBCs decreased (-1.392, -1.749 to -1.035, p = 0.000) and hepcidin-25 increased (0.297, 0.239 to 0.355, p = 0.000). Limiting erythropoiesis to maintain hemoglobin levels induces RBC reduction in hemodialysis patients, resulting in increased hepcidin-25 and FTN levels. Hepcidin-25 production may prompt an iron shift from RBC iron to FTN iron, inhibiting iron absorption even with continued FCH intake.

Evaluation of the effect of Remdesivir on some biomarkers in Iraqi patients with coronavirus 2019 (COVID-19): A cross-sectional study

COVID-19 is a new virus spreading worldwide that can cause mild to severe illness, multi-organ failure, and even death. Injectable antiviral Remdesivir is effective in treating patients with moderate-to-severe COVID-19. Biomarkers linked to clinical outcomes have been found for COVID-19, although only a few antiviral therapies have been studied. This study aimed to assess how Remdesivir affects several biomarkers in patients with COVID-19 and how those changes impact the severity of the illness. According to Chinese care guidelines for COVID-19, 80 patients with COVID-19 were separated into two groups: group 1 did not receive Remdesivir (RDV) medication and Group 2 received it after 5 days. Injectable antiviral Remdesivir has recently been tested in high-risk, individuals with confirmed SARS-CoV-2 infection who were not hospitalized, and it successfully delayed the onset of the illness. From February 2022 to October 2023, blood samples were taken from study participants to evaluate ferritin, Lactate Dehydrogenase (LDH), and C-reactive protein. The results of this investigation showed that various COVID-19 severity biomarkers, including ferritin, C-reactive protein, and lactate dehydrogenase, may improve more quickly with RDV treatment. These biomarkers are linked to better clinical outcomes during infection. These discoveries enhance the understanding of the COVID-19 antiviral treatment's function. In conclusion, there is a clear association between the levels of biomarkers before and after Remdesivir treatment in COVID-19 cases ranging from moderate to severe. This suggests that the COVID-19 infection might lead to the elevation of several biomarkers.

Defining an optimal cut-off point for reticulocyte hemoglobin as a marker for iron deficiency anemia: An ROC analysis

Reticulocyte hemoglobin (CHr) is a measure of the amount of hemoglobin in reticulocytes and a marker of cell hemoglobinization. In this study, we aimed to find the optimal cut-off point for reticulocyte hemoglobin to diagnose iron deficiency anemia using multiple methods. A total of 309 patients were included. The median age at diagnosis was 54 years. Most were females (71.2%). 68% had iron deficiency anemia. Patients with IDA had significantly lower levels of CHr compared to those who had non-IDA (p < 0.0001). The optimal cut-off value of CHr for detecting IDA, determined using various methods, was 30.15 pg. This cut-off point had a sensitivity of 87.8% and a specificity of 77.7%. CHr showed a significant positive correlation with hemoglobin, mean corpuscular volume, serum iron, serum ferritin, and transferrin saturation and a significant negative correlation with total iron-binding capacity. CHr levels correlate with most established laboratory tests for IDA. It reliably detects IDA. Our results indicate the importance of CHr in diagnosing IDA, and that CHr should be used more widely in suspected cases of IDA since it is a cheap, fast, and reliable test.

Prevention and Management of Iron Deficiency/Iron-Deficiency Anemia in Women: An Asian Expert Consensus

The lack of standardized clinical practice impeding the optimal management of iron deficiency (ID) and iron deficiency anemia (IDA) in women is a global concern, particularly in the Asia-Pacific region. The aim of this study was to determine best practices through a Delphi consensus process. In Round 1, panelists were asked to rate their level of agreement with 99 statements across four domains: identification, diagnosis and assessment, prevention, and treatment of ID/IDA in women. In Round 2, panelists reappraised their ratings in view of the collective feedback and responses to Round 1. After two rounds, consensus (≥85% agreement) was reached for 84% of the Delphi statements. Experts agreed on the role of presenting symptoms and risk factors in prompting assessments of anemia and iron status in women. Experts repeatedly called for prevention, recommending preventive iron supplementation for pregnant women irrespective of anemia prevalence levels, and for non-pregnant adult women, adolescent girls, and perimenopausal women living in areas with a high prevalence of anemia. Experts unanimously agreed to prescribing oral ferrous iron as first-line therapy for uncomplicated ID/IDA. The recommendations and clinical pathway algorithms generated should be used to inform clinical practice and standardize the care of women at risk or presenting with ID/IDA in the Asia-Pacific region.

A novel view of ferritin in cancer

Since its discovery more than 85 years ago, ferritin has principally been known as an iron storage protein. However, new roles, beyond iron storage, are being uncovered. Novel processes involving ferritin such as ferritinophagy and ferroptosis and as a cellular iron delivery protein not only expand our thinking on the range of contributions of this protein but present an opportunity to target these pathways in cancers. The key question we focus on within this review is whether ferritin modulation represents a useful approach for treating cancers. We discussed novel functions and processes of this protein in cancers. We are not limiting this review to cell intrinsic modulation of ferritin in cancers, but also focus on its utility in the trojan horse approach in cancer therapeutics. The novel functions of ferritin as discussed herein realize the multiple roles of ferritin in cell biology that can be probed for therapeutic opportunities and further research.

Multiple metal exposure and metabolic syndrome in elderly individuals: A case-control study in an active mining district, Northwest China

The prevalence of metabolic syndrome (MetS) is increasing at an alarming rate worldwide, particularly among elderly individuals. Exposure to various metals has been linked to the development of MetS. However, limited studies have focused attention on the elderly population living in active mining districts. Participants with MetS (N = 292) were matched for age (±2 years old) and sex with a healthy subject (N = 292). We measured the serum levels of 14 metals in older people aged 65-85 years. Conditional logistic regression, restricted cubic spline model, multiple linear regression, and Bayesian Kernel Machine Regression (BKMR) were applied to estimate potential associations between multiple metals and the risk of MetS. Serum levels of Sb and Fe were significantly higher than the controls (0.58 μg/L vs 0.46 μg/L, 2167 μg/L vs 2042 μg/L, p < 0.05), while Mg was significantly lower (20035 μg/L vs 20,394 μg/L, p < 0.05). An increased risk of MetS was associated with higher serum Sb levels (adjusted odds ratio (OR) = 1.61 for the highest tertile vs. the lowest tertile, 95% CI = 1.08-2.40, p-trend = 0.018) and serum Fe levels (adjusted OR = 1.55 for the highest tertile, 95% CI = 1.04-2.33, p-trend = 0.032). Higher Mg levels in serum may have potential protective effects on the development of MetS (adjusted OR = 0.61 for the highest tertile, 95% CI = 0.41-0.91, p-trend = 0.013). A joint exposure analysis by the BKMR model revealed that the mixture of 12 metals (except Tl and Cd) was associated with increased risk of MetS. Our results indicated that exposure to Sb and Fe might increase the risk of MetS in an elderly population living in mining-intensive areas. Further work is needed to confirm the protective effect of Mg on MetS.

Control variables of serum ferritin concentrations in hospitalized newborn infants: an observational study

Both iron excess and deficiency are deleterious to cellular and organ homeostasis. Serum ferritin levels serve as a biomarker of iron storage; however, their distribution and determinants in sick newborn infants remain unclear. This study aimed to investigate the reference range and independent variables of serum ferritin in hospitalized newborn infants. All newborn infants who were hospitalized at a tertiary neonatal center within 24 h of birth were retrospectively reviewed for the period of April 2015 through March 2017. Serum ferritin levels were assessed using venous blood samples obtained at admission and their independent variables were explored. The study population comprised 368 infants (36.2 ± 2.8 weeks gestation and 2319 ± 623 g at birth), whose median serum ferritin level was 149 µg/L (inter-quartile range: 81-236). The multivariable model used to explain serum ferritin values comprised hemoglobin, lactate dehydrogenase, blood pH, and maternal hypertensive disorders in pregnancy (all p < 0.01, adjusted for sex and birth weight). Serum ferritin values in hospitalized newborn infants were comparable to those previously reported using umbilical cord blood. Our novel findings indicated the association between blood pH, lactate dehydrogenase, and ferritin levels, suggesting the influence of antenatal hypoxia-ischemia and stress to serum ferritin levels.

Associations of micronutrients exposure with cadmium body burden among population: A systematic review

BACKGROUND

The absorption and accumulation of cadmium (Cd) within the human body can be influenced by the status of certain micronutrients, while available evidence for the association between micronutrient exposure and Cd body burden remains fragmented and inconsistent. To address this issue, this article reviews and synthesizes epidemiological studies that examine the association between micronutrient exposure and Cd burden in humans, to elucidate the potential association between micronutrient exposure and Cd body burden.

METHODS

We conducted a systematic review of epidemiologic studies reporting the association between micronutrient status and Cd body burden among the population. Relevant articles were selected based on predetermined criteria from PubMed, Web of Science, and Scopus databases published from 2000 to 2021. The exposures that were evaluated included micronutrients (zinc, selenium, iron, calcium, and vitamins) status or intakes of them. The outcome of interest was the Cd body burden as indicated by blood Cd or urinary Cd levels. The quality of included studies was assessed using The Joanna Briggs Institute critical appraisal tool. We extracted data from each article, including study design, study site, study population, micronutrient status, Cd body burden, and the correlations between micronutrient status and Cd body burden.

RESULTS

Our systematic search yielded 1660 articles. Of these, forty-four were selected for inclusion based on prespecified criteria. These selected articles evaluated the relationship between Cd body burden and seven different micronutrients, namely, selenium (Se), zinc (Zn), calcium (Ca), iron (Fe), vitamin A, vitamin B12, and vitamin D. The majority of studies (n = 41) were observational, while only three were randomized controlled trials. Among the seventeen studies assessing Zn status, ten reported a negative association between serum Zn levels or intake and urinary and blood Cd levels. Results were inconsistent among the ten studies examining the association between Se levels and Cd body burden. Six studies showed that Cd in blood and urine was negatively correlated with serum ferritin (SF), a biomarker of body Fe status. Two studies reported a negative correlation between Ca and blood Cd.

CONCLUSIONS

This synthesis of available evidence suggests that certain micronutrients, especially Zn and Fe, may play a role in reducing the Cd body burden among populations. The evidence strongly supports a negative association between Zn, Fe, and Cd body burden, whereas evidence for Se, Ca and vitamins is insufficient to draw definitive conclusions regarding their relationship with Cd body burden. In addition, observational studies limit the ability to infer a causal relationship between micronutrients and Cd body burden, highlighting the need for additional intervention studies. Our review may inform nutrient supplementation guidance, control of Cd body burden, and future research to mitigate the adverse health effects of Cd in the context of global Cd pollution.

Exposure to a static magnetic field attenuates hepatic damage and function abnormality in obese and diabetic mice

Static magnetic fields (SMFs) exhibit significant effect on health care. However, the effect of SMF on hepatic metabolism and function in obesity and diabetes are still unknown. Liver is not only the main site for glucolipid metabolism but also the core part for iron metabolism regulation. Dysregulations of iron metabolism and redox status are risk factors for the development of hepatic injury and affect glucolipid metabolism in obesity and diabetes. Mice of HFD-induced obesity and HFD/streptozocin-induced diabetes were exposed to a moderate-intensity SMF (0.4-0.7 T, direction: upward, 4 h/day, 8 weeks). Results showed that SMF attenuated hepatic damage by decreasing inflammation and fibrosis in obese and diabetic mice. SMF had no effects on improving glucose/insulin tolerance but regulated proteins (GLUT1 and GLUT4) and genes (G6pc, Pdk4, Gys2 and Pkl) participating in glucose metabolism with phosphorylation of Akt/AMPK/GSK3β. SMF also reduced lipid droplets accumulation through decreasing Plin2 and Plin5 and regulated lipid metabolism with elevated hepatic expressions of PPARγ and C/EBPα in obese mice. In addition, SMF decreased hepatic iron deposition with lower FTH1 expression and modulated systematic iron homeostasis via BMP6-mediated regulation of hepcidin. Moreover, SMF balanced hepatic redox status with regulation on mitochondrial function and MAPKs/Nrf2/HO-1 pathway. Finally, we found that SMF activated hepatic autophagy and enhanced lipophagy by upregulating PNPLA2 expression in obese and diabetic mice. Our results demonstrated that SMF significantly ameliorated the development of hepatic injury in obese and diabetic mice by inhibiting inflammatory level, improving glycolipid metabolism, regulating iron metabolism, balancing redox level and activating autophagy.

Anemia and Poor Iron Indices Are Associated With Susceptibility to Febrile Seizures in Children: A Systematic Review and Meta-analysis

INTRODUCTION

Febrile seizures are the most common type of seizure in children under the age of 5, and a number of risk factors for this condition have been identified. Several studies have examined the connection between iron deficiency anemia and febrile seizures in children, with inconsistent results. As a result, the authors sought to determine the precise link between iron deficiency anemia and its indices (mean corpuscular volume, serum iron, total iron-binding capacity, and ferritin) in conjunction to febrile seizures. Methods: A systematic literature search from several databases (PubMed, Europe PMC, ScienceDirect) was conducted from database inception until November 30, 2022. Studies were eligible if they investigated the relationship of the iron deficiency anemia and the aforementioned indices with the likelihood of febrile seizures. Results: This meta-analysis comprised 20 case-control studies with a total of 3856 participants. Our study revealed that iron deficiency anemia, low mean corpuscular volume, low serum iron, high total iron-binding capacity, and low ferritin were associated with the incremental risk of developing febrile seizures, with the odds ratios ranging from 1.24 to 1.59. Moreover, diagnostic test accuracy meta-analysis indicated that low serum ferritin level had the highest overall area under the curve value amid other iron deficiency anemia indices regarding our outcomes of interest. Conclusion: This study suggest that iron deficiency anemia and poor iron indices are associated with increased risk of febrile seizures in children.

Association of iron metabolism markers, socioeconomic and lifestyle factors with endometriosis: A cross-sectional study

BACKGROUND

Evidence on the link between iron metabolism markers and endometriosis is limited. We aimed to investigate the associations of iron metabolism markers, including serum ferritin level and transferrin saturation, with endometriosis.

METHODS

This study involved 6551 participants from the National Health and Nutrition Examination Survey (NHANES). Univariable and multivariable logistic regression analyses were used to examine the linear relationships between iron metabolism markers and endometriosis. Furthermore, restricted cubic splines were used to identify the non-linear dose-response associations.

RESULTS

Univariable analysis showed that the factors associated with endometriosis included age, race, education level, and smoking status. In multivariable model, compared with lowest quartile, highest quartile of serum ferritin level was positively associated with endometriosis (OR: 2.11, 95% confidence intervals [CI]: 1.31, 3.40, P = 0.004), and third quartile of transferrin saturation positively associated with endometriosis (OR: 1.55, 95% CI: 1.05, 2.29, P = 0.033). The restricted cubic splines showed the non-linear (inverted U-shape) associations between serum ferritin level and transferrin saturation and endometriosis (all P for non-linear＜0.01), indicating that the ORs of endometriosis increased with serum ferritin level and transferrin saturation up to the turning point and thereafter the ORs of endometriosis did not significantly increase with the increasing serum ferritin and transferrin saturation.

CONCLUSIONS

Our findings suggests that serum ferritin level and transferrin saturation were positively associated with endometriosis. Serum ferritin and transferrin saturation may be an important marker for endometriosis. Future prospective and longitudinal studies are necessary to better understand these findings.

Associations of Dietary Patterns and Vitamin D Levels with Iron Status in Pregnant Women: A Cross-Sectional Study in Taiwan

Vitamin D is involved in the pathophysiology of anemia. This cross-sectional study was conducted using the Nationwide Nutrition and Health Survey in Pregnant Women in Taiwan database. We investigated associations among dietary patterns (DPs), vitamin D, and iron-related biomarkers in pregnant women. The principal component analysis revealed four DPs. Linear and logistic regression analyses were performed to investigate the association of DPs with anemia-related biomarkers. Plant-based, carnivore, and dairy and nondairy alternatives DPs were positively associated with serum vitamin D levels. After adjusting covariates, the pregnant women consuming plant-based DPs at the mid-tertile (T2) were associated with reduced risks of low serum folate and vitamin D levels, and those consuming carnivore DPs at higher tertiles (T2 and/or T3) were correlated with an increased risk of low serum iron levels but decreased risks of low serum transferrin saturation, vitamin B₁₂, and vitamin D levels. The pregnant women consuming dairy and nondairy alternatives DPs at the highest tertile (T3) were associated with reduced risks of low serum folate and vitamin B₁₂ levels. However, the processed food DP was not correlated with anemia-related biomarkers. Thus, plant-based, carnivore, and dairy and nondairy alternatives DPs were associated with the risk of low-serum-anemia-related variables.

Micronutrient Deficiency in Children and Adolescents with Obesity-A Narrative Review

Childhood obesity represents a serious public health burden. Despite excessive dietary consumption, children with obesity present high rates of micronutrient deficiencies, such as deficiencies in minerals and specific vitamins; micronutrient deficiencies may have a pathogenic role in obesity-related metabolic comorbidities. In this narrative review, we analyzed the main deficiencies associated with obesity, their clinical consequences, and the evidence about a possible supplementation. Iron; vitamins A, B, C, D, and E; folic acid; zinc; and copper deficiencies represent the most common deficient microelements. The relationship between obesity and multiple micronutrient deficiencies remains unclear, and different mechanisms have been proposed. The medical care plan for pediatric obesity should include food choices with high nutritional content as part of a crucial approach to obesity-related complications. Unfortunately, only a few studies are available regarding the efficacy of oral supplementation or weight loss for treating them; thus, continuous nutritional monitoring is necessary.

A randomized controlled trial of thrice-weekly versus thrice-daily oral ferrous fumarate treatment in adult patients with iron-deficiency anemia

Iron deficiency anemia (IDA) is a common health problem in developing countries. Many studies have shown that low-dose oral iron could have similar efficacy and less gastrointestinal effects in iron deficiency without anemia. This prospective open-labeled randomized controlled study was designed to compare the response of 200 mg ferrous fumarate thrice-weekly (TIW) as not inferior to the thrice-daily (TID) regimen and to assess the incidence of adverse events (AEs) between two regimens in treating adult patients with IDA. The primary endpoint was either an increase in Hb ≥ 3 g/dL, having Hb of 12 g/dL in females or 13 g/dL in males at the 12th week of treatment. Secondary outcomes included adverse events (AEs), red blood cell indices, iron profiles, and patient compliance. Sixty-four patients were randomized: 32 in the TIW arm and the other 32 in the TID arm. The response rates were not different between two arms either with intention to treat analysis (72.0%, 95%CI 56.6-88.5 vs. 71.9%, 95%CI 53.3-86.3, p = 0.777); or per-protocol analysis (88.9%, 95%CI 70.8-97.6 vs. 88.5%, 95%CI 69.8-97.6, p = 1.0), respectively. The trial demonstrated non-inferiority at a margin of 23%. Although the iron profile response of the TID arm was earlier than the TIW arm, almost all patients recovered from anemic symptoms at week 4, and hematologic responses were not different at week 12. There were more gastrointestinal AEs in the TID arm. In conclusion, this study showed that the TIW was non-inferior to the TID iron treatment of IDA patients but less AEs and costs.

Ferritin But Not Iron Increases in Retina Upon Systemic Iron Overload in Diabetic and Iron-Dextran Injected Mice

Purpose

Iron overload causes oxidative damage in the retina, and it has been involved in the pathogeny of diabetic retinopathy, which is one of the leading causes of blindness in the adult population worldwide. However, how systemic iron enters the retina during diabetes and the role of blood retinal barrier (BRB) in this process remains unclear.

Methods

The db/db mouse, a well-known model of type 2 diabetes, and a model of systemic iron overload induced by iron dextran intraperitoneal injection, were used. Perls staining and mass spectrophotometry were used to study iron content. Western blot and immunohistochemistry of iron handling proteins were performed to study systemic and retinal iron metabolism. BRB function was assessed by analyzing vascular leakage in fundus angiographies, whole retinas, and retinal sections and by studying the status of tight junctions using transmission electron microscopy and Western blot analysis.

Results

Twenty-week-old db/db mice with systemic iron overload presented ferritin overexpression without iron increase in the retina and did not show any sign of BRB breakdown. These findings were also observed in iron dextran-injected mice. In those animals, after BRB breakdown induced by cryopexy, iron entered massively in the retina.

Conclusions

Our results suggested that BRB protects the retina from excessive iron entry in early stages of diabetic retinopathy. Furthermore, ferritin overexpression before iron increase may prepare the retina for a potential BRB breakdown and iron entry from the systemic circulation.

Correlation between high serum ferritin levels and adverse pregnancy outcomes in women with gestational diabetes mellitus

Aims

To explore the association between higher serum ferritin (SF) levels in mid-pregnancy and adverse pregnancy outcomes in gestational diabetes mellitus (GDM) pregnancies, then develop a predictive cut-off value that might effectively predict the risk of adverse pregnancy outcomes in future clinical.

Methods

The study involved 201 pregnant women with GDM. 201 gestational age and parity matched normoglycemic pregnant women were taken as control group. The differences in clinical data were compared by the Mann-Whitney U test and Chi-square tests. Multivariate logistic regression was used to determine the relationship between SF and GDM-relate adverse pregnancy outcomes. The predicted value of SF level was determined through receiver operating characteristic (ROC) curve analysis.

Results

SF level was significantly higher in women with GDM [16.10 (27.30-9.50) (ng/mL) vs. 12.04 (18.11-7.06) (ng/mL), (p < 0.001)]. Meanwhile, higher levels of SF were also discovered in GDM women with preeclampsia and neonatal hypoglycemia and respiratory distress (all p < 0.05). In the adjusted model, a positive association was shown between SF and preeclampsia [adjusted odds ratio (AOR) = 1.032, 95%CI = 1.004-1.060, p = 0.024], neonatal hypoglycemia [adjusted odds ratio (AOR) = 1.047, 95%CI = 1.022-1.072, p < 0.001] and respiratory distress outcomes (AOR = 1.034, 95%CI = 1.011-1.058, p = 0.004) respectively. The area under ROC curve (AUC) for prediction of preeclampsia by SF combined with serum calcium, age, pre-pregnancy BMI and gestational weight gain (GWG) was 0.658 (95% CI = 50.8-80.8%, p = 0.028) with the cut-off value of 24.45 ng/mL, and the sensitivity and specificity were 58.8.0% and 64.3%, respectively. To predict neonatal hypoglycemia, the clinical point value of SF was 27.43 ng/mL with AUC was 0.800, sensitivity and specificity was 90.5% and 68.0% respectively. Predicting neonatal respiratory distress, the AUC value of the SF level was 0.730, with a cut-off value of 27.37 ng/mL and the sensitivity and specificity were 52.0% and 86.5%, respectively.

Conclusions

Higher level of SF in mid-pregnancy was significantly associated with the risk of GDM and GDM-relate adverse pregnancy outcomes. Moreover, SF levels have moderate clinical value in predicting the adverse outcomes of maternal preeclampsia, neonatal hypoglycemia and respiratory distress.

Impact of iron supplementation on gestational diabetes mellitus: A literature review

Gestational diabetes mellitus (GDM) is a common complication of pregnancy, affecting 14% of pregnancies worldwide, and the prevention of pathological hyperglycaemia during pregnancy is meaningful for global public health. The role of iron supplementation in the progression of GDM has been of significant interest in recent years. Iron is a micronutrient that is vital during pregnancy; however, given the toxic properties of excess iron, it is probable that prophylactic iron supplementation will increase the risk of adverse pregnancy outcomes, including GDM. It is critical to clarify the effect of iron supplementation on the risk of GDM. Therefore, in this review, we comprehensively assess the role of iron in pregnancy. This review aimed to analyse the necessity of iron supplementation and maintenance of iron homeostasis during pregnancy, particularly reviewing the role and function of iron in beta cells and examining the mechanisms of excess iron contributing to the pathogenesis of GDM. Moreover, we aimed to discuss the association of haemoglobin and ferritin with GDM and identify priority areas for research.

Ferritin screening and Iron treatment for maternal anemia and fetal growth restriction prevention - A multicenter randomized controlled trial (FAIR Study)

Background

Non-anemic iron deficiency precedes iron deficiency anaemia and has an estimated prevalence of 1-2 billion worldwide. Few studies have comprehensively researched the idea of treating non-anemic iron deficiency (NAID) with iron to improve the outcome of the mother and the offspring.

Methods and Analysis

FAIR will be a multicenter randomized controlled trial that will be conducted in multiple clinical academic obstetrics units in Lahore (including Services Institute of Medical Sciences, Lahore, Allama Iqbal Medical College, Lahore and Fatima Jinnah Medical University). Pregnant women at gestational age <20 weeks with hemoglobin 11-13 g/L and ferritin below the threshold (<30 ng/ml) will be invited to take part in the study. Randomization will be done by computer based generated random numbers. One group (usual care or oral group) will be offered routine care prophylactic dose of oral iron (30-45 mg/day) and the other group (intervention arm or IV group) will be offered therapeutic dose of IV iron (dose calculated by Ganzoni formula) in addition to usual care. All patients will be followed up till delivery. Primary maternal outcome will be hemoglobin at 36 weeks' gestation. Secondary outcomes are fetal birthweight or small for gestational age, preterm birth, preeclampsia, multidimensional fatigue inventory, breast feeding initiation, blood transfusion, and fetal cord ferritin and hemoglobin.

Discussion

The study will generate evidence as to whether screening serum ferritin in non-anemic pregnant women and replenishing their iron stores will likely reduce the rate of predelivery anemia in pregnant women, improve birthweight and preventing perinatal complications.

Roles and responsibilities

Tayyiba Wasim is principal Investigator and other members of data management team are Natasha Bushra, Shamsa Humayoun, Khalid Saeed Khan, Fatima Shehbaz, Saba Rasool, Anam Riaz and Sonia Irshad. Principal investigator will assume the full responsibility of Fair trial including training of research assistants, administration of informed consent and protecting participants confidentiality. Data management team will help in the management, development and execution of trial. Khadija Irfan Khawaja is the operational lead for fair trial´s technology team comprising of Aziz Fatima and Zubia Zafar, responsible for gathering requirements from study teams and supporting the operational implementation of technology to drive the collection of high-quality study data. Protocol contributors are Gynae unit I of Services Institute of Medical Sciences/ Services hospital, Lahore, Gynae Unit II of Allama Iqbal Medical College/ Jinnah hospital, Lahore and Gynae unit 1 of Fatima Jinnah Medical College/ Sir Ganga Ram hospital, Lahore. These coordinating centres will recruit patients (sample size=600) and will discuss their progress in trial management meetings quarterly.

Steering committee

has an independent chair Prof Samia Malik, one expert member Prof Faiza Bashir and Ms Neelam to represent patients, public and consumers. Trial steering committee with independent chair and member with a patient representative will oversee the study. Chair of steering committee has the authority to stop the trial whenever needed in case of positive or negative results. Steering committee meetings will be held on annual basis.

Independent Data monitoring committee

comprises of Dr. Shehnoor Azhar as chair and Prof Ejaz Hussain and Dr. Shehla Javed Akram as members. Data monitoring committee will assess the progress, data safety and if needed critical efficacy points of the clinical study and will show their results quarterly in data interim meetings. The committee will focus on integrity of the whole process and compliance of all sites with all aspects of the protocol. It will perform confidential interim analyses quarterly, which may be used to determine if an effect is observed and if the study should continue to its planned sample size. Data monitoring committee will report to the Chair of the steering committee.

Standardisation and application of a novel multiplex assay for estimating micronutrient status and inflammatory markers in women of Sauria Paharia and Santhal tribes of Jharkhand

This study aimed to document the method standardisation and assessment of micronutrient and inflammatory markers in women from indigenous tribal communities of Jharkhand using a low-volume, high-throughput assay. This cross-sectional study was done among women of the reproductive age group from Sauria Paharia and Santhal tribal households (HH) in selected villages. Capillary blood samples were collected from the women during a HH survey to estimate ferritin, soluble transferrin receptor, retinol binding protein 4 and inflammatory biomarkers, C-reactive protein (CRP) and α-1-acid glycoprotein (AGP) using a multiplex assay. Vitamin D and Hb were estimated using an LC-MS technique and cyanmethaemoglobin method, respectively. A multiplex Luminex-based method was developed and standardised. The assay was used to estimate biomarkers in samples from 413 women (178 and 235 from Sauria Paharia and Santhal tribes, respectively). Over 51 % of women had raised CRP or AGP levels. Fe status was significantly better in Sauria Paharia compared with the Santhal women. Anaemia prevalence was 72 % among Santhal women. The proportion of women with Fe deficiency increased after adjusting for inflammation. The overall prevalence of vitamin A deficiency and insufficiency was 25 and 34 %, respectively, with similar prevalence in both tribes. All Santhal women had sufficient vitamin D levels, while 25 and 20 % of Sauria Paharia women had insufficient and deficient vitamin D levels, respectively. Our low-volume, high-throughput multiplex assays may provide a feasible approach for assessing nutritional biomarkers in nutritionally vulnerable hard-to-reach communities.

Significance of low ferritin without anaemia in screen-detected, adult coeliac disease patients

BACKGROUND

Low ferritin without anaemia has been linked to adverse health effects.

OBJECTIVES

To investigate the prevalence and clinical significance of low ferritin in screen-detected coeliac disease.

METHODS

Seventy-six screen-detected coeliac disease patients were enrolled in the prospective collection of comprehensive clinical, laboratory and histological data at diagnosis and after 1-2 years on a gluten-free diet (GFD). All variables were compared between patients with different ferritin levels.

RESULTS

At coeliac disease diagnosis, six patients had anaemia. Of the 70 nonanaemic patients, ferritin levels were <15 μg/L in 21%, 15-29 μg/L in 19%, 30-99 μg/L in 36% and ≥100 μg/L in 24%. Those with lower ferritin were more often females, had lower body mass index, haemoglobin and villous height-crypt depth ratio and also had higher intra-epithelial lymphocyte CD3+ levels in duodenal biopsies. The groups did not differ in neurological or gastrointestinal symptoms, health-related quality of life, bone mineral density, liver values, vitamin, albumin or coeliac autoantibody levels or the prevalence of comorbidities. Median ferritin levels increased from 41.5 μg/L to 86.0 μg/L on GFD (p < 0.001). Ferritin remained <30 μg/L in 21% of patients but was not associated with dietary compliance, nor was any correlation between changes in ferritin and quality of life, gastrointestinal symptoms, autoantibody levels or degree of histological damage detected.

CONCLUSION

Decreased ferritin is a frequent finding in screen-detected coeliac disease and may not be fully restored on a GFD. However, low ferritin levels are not associated with more severe symptoms or poorer quality of life.

Association between serum ferritin and bone mineral density in US adults

Background

The association between serum ferritin and bone mineral density (BMD) is still controversial. This study aims to investigate the association of serum ferritin level with BMD in US adults.

Methods

We conducted a cross-sectional study consisting of 8445 participants from National Health and Nutrition Examination Survey. Serum ferritin and lumbar spine BMD were used as independent variables and dependent variables, respectively. We evaluated the association between serum ferritin and lumbar spine BMD through a weighted multivariable linear regression model. Subgroup and interaction analysis was also performed in this study.

Results

After adjusting for other confounding factors, serum ferritin was negatively correlated with lumbar spine BMD [β =  − 0.090, 95% CI (− 0.135, − 0.045)]. Further subgroup analysis found that the strongest negative association mainly exists in females aged over 45 years [β =  − 0.169, 95% CI (− 0.259, − 0.079)], and this association is not significant in other groups.

Conclusions

The results found that the association between serum ferritin and lumber spine BMD differed by gender and age. Increased level of serum ferritin may indicate a higher risk of osteoporosis or osteopenia in females aged over 45 years.

Host and microbiota derived extracellular vesicles: Crucial players in iron homeostasis

Iron is a double-edged sword. It is vital for all that’s living, yet its deficiency or overload can be fatal. In humans, iron homeostasis is tightly regulated at both cellular and systemic levels. Extracellular vesicles (EVs), now known as major players in cellular communication, potentially play an important role in regulating iron metabolism. The gut microbiota was also recently reported to impact the iron metabolism process and indirectly participate in regulating iron homeostasis, yet there is no proof of whether or not microbiota-derived EVs interfere in this relationship. In this review, we discuss the implication of EVs on iron metabolism and homeostasis. We elaborate on the blooming role of gut microbiota in iron homeostasis while focusing on the possible EVs contribution. We conclude that EVs are extensively involved in the complex iron metabolism process; they carry ferritin and express transferrin receptors. Bone marrow-derived EVs even induce hepcidin expression in β-thalassemia. The gut microbiota, in turn, affects iron homeostasis on the level of iron absorption and possibly macrophage iron recycling, with still no proof of the interference of EVs. This review is the first step toward understanding the multiplex iron metabolism process. Targeting extracellular vesicles and gut microbiota-derived extracellular vesicles will be a huge challenge to treat many diseases related to iron metabolism alteration.

Implication of asymptomatic and clinical Plasmodium falciparum infections on biomarkers of iron status among school-aged children in Malawi

Background

Iron status is considered as a continuum from an iron deficiency with anaemia, without anaemia, varying amounts of stored iron to iron overload. The burden of Plasmodium falciparum infections is typically high among school-aged children (SAC). Nonetheless, SAC are often less likely to be covered by malaria interventions, making them a group with an untreated reservoir of parasite transmission. This study aimed to assess the effects of asymptomatic and clinical malaria infections on biochemical markers of iron status among SAC in Malawi.

Methods

Data from the 2015–2016 Malawi Micronutrient Survey (MNS) was used and multivariable logistic regression models using a generalized estimating equation to account for the complex cluster survey design were constructed. Blood samples of 684 children aged 5 to 14 years old were evaluated for clinical and asymptomatic malaria infections. Furthermore, blood samples were used to estimate haemoglobin (Hb), serum ferritin (SF) and, soluble transferrin receptors (sTfR) concentrations.

Results

Of the 684 SAC analysed, approximately 42% had asymptomatic malaria, while 41.0% had clinical malaria. Anaemia (low Hb levels), iron deficiency (low SF concentration), and functional iron deficiency (high sTfR levels) were found in 20%, 5%, and 30% of the children, respectively. School-aged children with asymptomatic malaria had increased odds of being anaemic (adjusted odds ratio [aOR]: 3.71, 95% confidence interval [CI]: 2.29–5.99) and increased levels of sTfR (aOR: 3.00, 95% CI 2.01–4.47). Similarly, SAC with clinical malaria had increased odds of being anaemic (aOR: 3.54, 95% CI 2.19–5.72) and increased levels of sTfR (aOR: 3.02, 95% CI 2.02–4.52).

Conclusions

Both asymptomatic and clinical malaria were independent risk factors for anaemia and functional iron deficiency (FID). The notion that asymptomatic and clinical malaria were associated with both anaemia and FID underscores the need for public health programmers to consider adding mass screening and treatment for malaria to existing school-based health programmes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04297-1.

Reticulocyte Hemoglobin-Equivalent Potentially Detects, Diagnoses and Discriminates between Stages of Iron Deficiency with High Sensitivity and Specificity

Background: Iron deficiency anemia (IDA) is a global health problem affecting the quality of life of more than 2 billion individuals. The current practice guidelines diagnose and monitor IDA via conventional hematological and iron biomarkers, which take several months before they are corrected under an iron-treatment plan. Reticulocyte hemoglobin equivalent (Ret-He) is used as a marker in most new hematology analyzers to assess iron incorporation into erythrocyte hemoglobin directly. This study aims to examine the efficacy of Ret-He as a marker for iron deficiency (ID) and IDA and investigate whether Ret-He is sensitive to iron therapy. Methods: Two blood samples were drawn from 182 participants for CBC and iron profile measurements. Follow-up samples were drawn from participants with a confirmed diagnosis of ID and/or IDA. Results: Ret-He levels were lower in the ID and IDA groups compared to the control (p < 0.0001), and lower in the IDA group compared to the ID group (p < 0.0001). Ret-He was correlated with ferritin at ID level (<30.0 mg/mL; r = 0.39) and severe IDA (<13.0 ng/mL; p-value < 0.01, r = 0.57). Cut-off values of <28.25 pg for ID and <21.55 pg for IDA showed a higher specificity and sensitivity (ID; AUC: 0.99, sensitivity: 92.73%, specificity: 97.87%) and (IDA; AUC: 0.94, sensitivity: 90.63%, specificity: 92.31%). Finally, Ret-He successfully reflected the iron therapy (p < 0.001) when compared to hemoglobin (Hb) (p = 0.1). Conclusions: Ret-He is a potential marker for detecting and diagnosing different stages of ID with high validity and is very sensitive in reflecting the iron incorporation in a short time.

The "Iron Tale"- iron indices and handgrip strength in community-dwelling adults

Sarcopenia is a precursor for physical frailty and is associated with adverse outcomes. Low handgrip strength (HGS) is one of the diagnostic criteria for sarcopenia. Multiple factors can influence muscle quality, including muscle composition, architecture, fat infiltration, fibrosis, excessive iron deposition, and neural activation. There is limited evidence on the association of iron and HGS in community-dwelling older adults. We aim to examine the association of HGS with iron indices and inflammation. The Healthy Older People Everyday study is a subset of the Singapore Population Health Studies cohort. Complete cross-sectional data and iron indices were available for 477 participants. Sociodemographics, comorbidities, and final scores of the FRAIL scale, Barthel Index, Lawton Scale, HGS, and timed-up-and-go were collected and analyzed. Laboratory parameters including hemoglobin, hsCRP and iron indices were measured. The mean age of the participants was 70.9 ± 5.0 years, 258(54.1%) were females, and most were of Chinese(85.3%) ethnicity. Amongst the participants, 6.9% were frail, 39.4% were pre-frailt, and 53.7% were robust. Mean HGS was 22.2 ± 7.0 kg. Low HGS was prevalent in 47.8%, the highest amongst Indians. Prevalence of diabetes, chronic kidney disease, and ischaemic heart disease were significantly higher in those with low HGS. In multivariate regression adjusting for age, sex, comorbidities and Hb, ferritin (β = 0.004 95%CI 0.0002-0.007, p = 0.04), transferrin saturation (β = 0.06 95%CI 0.01-0.10, p = 0.02) and hsCRP (β = - 0.15 95%CI - 0.26 to - 0.04, p < 0.01) were significantly associated with HGS. CRP was negatively associated with HGS, whereas ferritin and transferrin saturation were positively associated with HGS. Older people with iron deficiency should be assessed for sarcopenia, and vice versa, as both can occur in multisystemic disorder, and need to be managed concurrently. Prospective longitudinal studies and clinical trials may be required to establish the causal effect of iron deficiency on muscle strength and sarcopenia and the benefits of iron therapy to improve function and quality of life.

Underdiagnosis of iron deficiency anaemia in HIV-infected individuals: a pilot study using soluble transferrin receptors and intensive bone marrow iron stores to improve the diagnosis

AIM

We compared soluble transferrin receptors (sTfR), serum ferritin, mean cell volume (MCV) of red cells and the sTfR-ferritin index with the intensive method bone marrow trephine (BMT) iron stores in the diagnosis of iron deficiency anaemia (IDA) in Human Immunodeficiency Virus (HIV)-positive hospitalised participants.

METHODS

In this cross-sectional study, we recruited hospitalised HIV-positive and coronavirus of 2019 (COVID-19)-negative adults with anaemia who required a bone marrow examination as part of their diagnostic workup. We measured the full blood count, ferritin, sTfR and assessed iron using the intensive method in Haemotoxylin and Eosin (H&E)-stained BMT core biopsies of consenting participants.

RESULTS

Of the 60 enrolled participants, 57 were evaluable. Thirteen (22.80%) had IDA on H&E BMT iron stores assessment, and 44 (77.19%) had anaemia of chronic diseases (ACD). The sTfR and the sTfR-ferritin index had sensitivities of 61.54% and 53.85%, respectively, for IDA diagnosis. The sensitivity and specificity of ferritin was 7.69% and 92.31%, respectively. The sTfR and sTfR-ferritin index's diagnostic specificity was relatively low at 46.15% and 38.46%, respectively.

CONCLUSION

In this pilot study in HIV-positive participants, the prevalence of iron deficiency using the BMT assessment was low. Both the sTfR and the sTfR-ferritin index had a better quantitative correlation to bone marrow iron stores when compared with the MCV and ferritin and, may be more accurate surrogate markers of IDA.

Total Iron Concentrations in Different Biological Matrices-Influence of Physical Training

Iron (Fe) is one of the most widely studied trace mineral elements. Fe metabolism and homeostasis could be altered by physical training. The aim of this study was to analyze the influence of long-term physical training on serum, plasma, urine (extracellular), erythrocyte and platelet (intracellular) Fe concentrations. Forty men from the same geographical area divided into a training group (TG; n = 20; 18.15 ± 0.27 years) and a control group (CG; n = 20; 19.25 ± 0.39 years) participated in this study. The TG was composed of soccer players of the highest youth category. The CG consisted of young people who did not follow any training routine and had not practiced any sport for at least the previous six months. The TG showed higher plasma and serum Fe concentrations (p < 0.05), but lower concentrations in erythrocytes and platelets compared to the CG (p < 0.01). Due to the differences observed in the extracellular and intracellular compartments, it seems necessary to perform a global Fe analysis to assess Fe status.

Iron-Induced Oxidative Stress in Human Diseases

Iron is responsible for the regulation of several cell functions. However, iron ions are catalytic and dangerous for cells, so the cells sequester such redox-active irons in the transport and storage proteins. In systemic iron overload and local pathological conditions, redox-active iron increases in the human body and induces oxidative stress through the formation of reactive oxygen species. Non-transferrin bound iron is a candidate for the redox-active iron in extracellular space. Cells take iron by the uptake machinery such as transferrin receptor and divalent metal transporter 1. These irons are delivered to places where they are needed by poly(rC)-binding proteins 1/2 and excess irons are stored in ferritin or released out of the cell by ferroportin 1. We can imagine transit iron pool in the cell from iron import to the export. Since the iron in the transit pool is another candidate for the redox-active iron, the size of the pool may be kept minimally. When a large amount of iron enters cells and overflows the capacity of iron binding proteins, the iron behaves as a redox-active iron in the cell. This review focuses on redox-active iron in extracellular and intracellular spaces through a biophysical and chemical point of view.

Optimizing iron supplementation by monitoring serum ferritin levels in premature infants

BACKGROUND

Iron (Fe) is essential for growth, but optimal intake is controversial. Our NICU practice was to supplement 2 mg/kg/d Fe for all preterm infants receiving human milk when they achieved full feeding volume. Adjusting Fe supplementation based on ferritin levels is thought to better address physiologic requirements. Our objective was to assess the impact of therapeutic monitoring of ferritin levels on the initiation and dosing of iron supplementation, hematocrit, transfusions, and oxygen radical diseases in preterm infants.

METHODS

Preterm infants (<  32 weeks gestation, n = 100) were included. Ferritin was measured when full feeds were achieved, and then every 2 weeks. Fe was started at 2 mg/kg/d or continued at current dose for ferritin 40-300μg/L, increased by 1-2 mg/kg/d for <  40μg/L, or discontinued for >  300μg/L. Outcomes were compared with a historical control group.

RESULTS

Ferritin levels were not predictable by dietary or transfusion histories. Using the ferritin protocol, 70% of infants received Fe at the time of full feeds, compared to 100% of controls. In contrast, all infants received Fe 4 weeks later, compared to 87% of controls. Mean age at Fe initiation increased (14.8±6.3 to 21.0±11.76 days). Peak doses were higher, with 32% receiving >  2 mg/kg day by 6 weeks, with fewer transfusions. The incidence of bronchopulmonary dysplasia and necrotizing enterocolitis did not change.

CONCLUSION

An iron protocol based on ferritin levels results in later initiation, higher doses, and fewer transfusions, without increasing oxygen radical diseases.

Associations of maternal iron deficiency with malaria infection in a cohort of pregnant Papua New Guinean women

BACKGROUND

Iron deficiency (ID) is common in malaria-endemic settings. Intermittent preventative treatment of malaria in pregnancy (IPTp) and iron supplementation are core components of antenatal care in endemic regions to prevent adverse pregnancy outcomes. ID has been associated with reduced risk of malaria infection, and correspondingly, iron supplementation with increased risk of malaria infection, in some studies.

METHODS

A secondary analysis was conducted amongst 1888 pregnant women enrolled in a malaria prevention trial in Papua New Guinea. Maternal ID was defined as inflammation-corrected plasma ferritin levels < 15 μg/L at antenatal enrolment. Malaria burden (Plasmodium falciparum, Plasmodium vivax) was determined by light microscopy, polymerase chain reaction, and placental histology. Multiple logistic and linear regression analyses explored the relationship of ID or ferritin levels with indicators of malaria infection. Models were fitted with interaction terms to assess for modification of iron-malaria relationships by gravidity or treatment arm.

RESULTS

Two-thirds (n = 1226) and 13.7% (n = 258) of women had ID and peripheral parasitaemia, respectively, at antenatal enrolment (median gestational age: 22 weeks), and 18.7% (120/1,356) had evidence of malaria infection on placental histology. Overall, ID was associated with reduced odds of peripheral parasitaemia at enrolment (adjusted odds ratio [aOR] 0.50; 95% confidence interval [95% CI] 0.38, 0.66, P < 0.001); peripheral parasitaemia at delivery (aOR 0.68, 95% CI 0.46, 1.00; P = 0.050); and past placental infection (aOR 0.35, 95% CI 0.24, 0.50; P < 0.001). Corresponding increases in the odds of infection were observed with two-fold increases in ferritin levels. There was effect modification of iron-malaria relationships by gravidity. At delivery, ID was associated with reduced odds of peripheral parasitaemia amongst primigravid (AOR 0.44, 95% CI 0.25, 0.76; P = 0.003), but not multigravid women (AOR 1.12, 95% CI 0.61, 2.05; P = 0.720). A two-fold increase in ferritin associated with increased odds of placental blood infection (1.44, 95% CI 1.06, 1.96; P = 0.019) and active placental infection on histology amongst primigravid women only (1.24, 95% CI 1.00, 1.54; P = 0.052).

CONCLUSIONS

Low maternal ferritin at first antenatal visit was associated with a lower risk of malaria infection during pregnancy, most notably in primigravid women. The mechanisms by which maternal iron stores influence susceptibility to infection with Plasmodium species require further investigation.

TRIAL REGISTRATION

Assessment of Iron Status in Adolescents Presenting to the Emergency Department With Heavy Menstrual Bleeding

OBJECTIVE

Iron deficiency is extremely common in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department; however, patients are rarely screened for this. The objective of this study was to evaluate screening for iron deficiency in adolescents presenting to the emergency department for HMB.

METHODS

This is a secondary analysis of a single-center, cross-sectional observational study using retrospective chart review. The study subjects are adolescents ages 11 to 19 years with International Classification of Diseases, Ninth Revision, Clinical Modification/International Classification of Diseases, Tenth Revision, Clinical Modification, codes for HMB who presented to the emergency department at a national tertiary care hospital from 2006 to 2018. Pregnant adolescents with HMB were excluded. Chart abstraction for demographic data, symptoms, laboratory tests, treatments, and outcomes was performed. The main outcome measure was the number of adolescents who had an iron evaluation in the emergency department and were discharged on oral iron.

RESULTS

Of the 258 nonpregnant adolescents who sought care for HMB in the emergency department, 225 (87.2%) were evaluated with serum hemoglobin testing. Ninety-four (41.7%) of those tested were anemic. Only 23 of the 258 patients (8.9%) had iron studies (serum ferritin) performed; 18 of 23 (78.3%) had iron deficiency and 21 of 23 (92.3%) were anemic. Subjects presenting with fatigue, headache, or palpitations were more likely to have iron studies performed than those without these symptoms (all P < 0.01). Thirty-two of the 258 subjects (12.4%) were discharged on oral iron therapy, which included only 15 of the 18 subjects (83.3%) with iron deficiency determined by ferritin testing.

CONCLUSIONS

Adolescents presenting to the emergency department with HMB are at significant risk of iron deficiency but are not being screened or treated, which may have significant consequences.

Iron imbalance in cancer: Intersection of deficiency and overload

Iron, an essential trace element, plays a complex role in tumour biology. While iron causes cancer clearance through toxic free radical generation, iron‐induced free radical flux also acts as a cancer promoter. These fates majorly guided through cellular response towards pro‐oxidant and antioxidant settings in a tumour microenvironment, designate iron‐induced oxidative stress as a common yet paradoxical factor in pro‐tumorigenesis as well as anti‐tumorigenesis, posing a challenge to laying down iron thresholds favouring tumour clearance. Additionally, complexity of iron's association with carcinogenesis has been extended to iron‐induced ROS's involvement in states of both iron deficiency and overload, conditions identified as comparable, inevitable and significant coexisting contributors as well as outcomes in chronic infections and tumorigenesis. Besides, iron overload may also develop as an unwanted outcome in certain cancer patients, as a result of symptomatic anaemia treatment owed to irrational iron‐restoration therapies without a prior knowledge of body's iron status with both conditions synergistically acting towards tumour aggravation. The co‐play of iron deficiency and overload along with iron's pro‐tumour and antitumour roles with intersecting mechanisms, thus presents an unpredictable regulatory response loop in a state of malignancy. The relevance of iron's thresholds beyond which it proves to be beneficial against tumorigenesis hence becomes questionable. These factors pose a challenge, over establishing if iron chelation or iron flooding acts as a better approach towards antitumour therapies. This review presents a critical picture of multiple contrasting features of iron's behaviour in cancer, leading towards two conditions lying at opposite ends of a spectrum: iron deficiency and overload in chronic disease conditions including cancer, hence, validating the critical significance of diagnosis of patients' iron status prior to opting for subsequent therapies.

Automated prediction of low ferritin concentrations using a machine learning algorithm

OBJECTIVES

Computational algorithms for the interpretation of laboratory test results can support physicians and specialists in laboratory medicine. The aim of this study was to develop, implement and evaluate a machine learning algorithm that automatically assesses the risk of low body iron storage, reflected by low ferritin plasma levels, in anemic primary care patients using a minimal set of basic laboratory tests, namely complete blood count and C-reactive protein (CRP).

METHODS

Laboratory measurements of anemic primary care patients were used to develop and validate a machine learning algorithm. The performance of the algorithm was compared to twelve specialists in laboratory medicine from three large teaching hospitals, who predicted if patients with anemia have low ferritin levels based on laboratory test reports (complete blood count and CRP). In a second round of assessments the algorithm outcome was provided to the specialists in laboratory medicine as a decision support tool.

RESULTS

Two separate algorithms to predict low ferritin concentrations were developed based on two different chemistry analyzers, with an area under the curve of the ROC of 0.92 (Siemens) and 0.90 (Roche). The specialists in laboratory medicine were less accurate in predicting low ferritin concentrations compared to the algorithms, even when knowing the output of the algorithms as support tool. Implementation of the algorithm in the laboratory system resulted in one new iron deficiency diagnosis on average per day.

CONCLUSIONS

Low ferritin levels in anemic patients can be accurately predicted using a machine learning algorithm based on routine laboratory test results. Moreover, implementation of the algorithm in the laboratory system reduces the number of otherwise unrecognized iron deficiencies.

Structural and functional relationship of mammalian and nematode ferritins

Ferritin is a unique buffering protein in iron metabolism. By storing or releasing iron in a tightly controlled manner, it prevents the negative effects of free ferrous ions on biomolecules in all domains of life - from bacteria to mammals. This review focuses on the structural features and activity of the ferritin protein family with an emphasis on nematode ferritins and the similarities in their biological roles with mammalian ferritins. The conservative characteristic of the ferritin family across the species originates from the ferroxidase activity against redox-active iron. The antioxidative function of these proteins translates into their involvement in a wide range of important biological processes, e.g., aging, fat metabolism, immunity, anticancer activity, and antipathogenic activity. Moreover, disturbances in ferritin expression lead to severe iron-associated diseases. Research on the Caenorhabditis elegans model organism may allow us to better understand the wide spectrum of mechanisms involving ferritin activity.

Distribution and Associated Factors of Hepatic Iron-A Population-Based Imaging Study

Hepatic iron overload can cause severe organ damage; therefore, an early diagnosis and the identification of potential risk factors is crucial. We aimed to investigate the sex-specific distribution of hepatic iron content (HIC) in a population-based cohort and identify relevant associated factors from a panel of markers. We analyzed N = 353 participants from a cross-sectional sample (KORA FF4) who underwent whole-body magnetic resonance imaging. HIC was assessed by single-voxel spectroscopy with a high-speed T2-corrected multi-echo technique. A large panel of markers, including anthropometric, genetic, and laboratory values, as well as behavioral risk factors were assessed. Relevant factors associated with HIC were identified by variable selection based on LASSO regression with bootstrap resampling. HIC in the study sample (mean age at examination: 56.0 years, 58.4% men) was significantly lower in women (mean ± SD: 39.2 ± 4.1 s^-1) than in men (41.8 ± 4.7 s^-1, p < 0.001). Relevant factors associated with HIC were HbA1c as well as prediabetes for men and visceral adipose tissue as well as age for women. Hepatic fat, alcohol consumption, and genetic risk score for iron levels were associated with HIC in both sexes. In conclusion, there are sex-specific associations of HIC with markers of body composition, glucose metabolism, and alcohol consumption.