Evaluation of Hemoglobin Cutoff Levels to Define Anemia Among Healthy Individuals

JAMA Netw Open. 2021 Aug 2;4(8):e2119123. doi: 10.1001/jamanetworkopen.2021.19123.


Importance: Anemia, defined as low hemoglobin (Hb) concentration insufficient to meet an individual's physiological needs, is the most common blood condition worldwide.

Objective: To evaluate the current World Health Organization (WHO) Hb cutoffs for defining anemia among persons who are apparently healthy and to assess threshold validity with a biomarker of tissue iron deficiency and physiological indicator of erythropoiesis (soluble transferrin receptor [sTfR]) using multinational data.

Design, setting, and participants: In this cross-sectional study, data were collected and evaluated from 30 household, population-based nutrition surveys of preschool children aged 6 to 59 months and nonpregnant women aged 15 to 49 years during 2005 to 2016 across 25 countries. Data analysis was performed from March 2020 to April 2021.

Exposure: Anemia defined according to WHO Hb cutoffs.

Main outcomes and measures: To define the healthy population, persons with iron deficiency (ferritin <12 ng/mL for children or <15 ng/mL for women), vitamin A deficiency (retinol-binding protein or retinol <20.1 μg/dL), inflammation (C-reactive protein >0.5 mg/dL or α-1-acid glycoprotein >1 g/L), or known malaria were excluded. Survey-specific, pooled Hb fifth percentile cutoffs were estimated. Among individuals with Hb and sTfR data, Hb-for-sTfR curve analysis was conducted to identify Hb inflection points that reflect tissue iron deficiency and increased erythropoiesis induced by anemia.

Results: A total of 79 950 individuals were included in the original surveys. The final healthy sample was 13 445 children (39.9% of the original sample of 33 699 children; 6750 boys [50.2%]; mean [SD] age 32.9 [16.0] months) and 25 880 women (56.0% of the original sample of 46 251 women; mean [SD] age, 31.0 [9.5] years). Survey-specific Hb fifth percentile among children ranged from 7.90 g/dL (95% CI, 7.54-8.26 g/dL in Pakistan) to 11.23 g/dL (95% CI, 11.14-11.33 g/dL in the US), and among women from 8.83 g/dL (95% CI, 7.77-9.88 g/dL in Gujarat, India) to 12.09 g/dL (95% CI, 12.00-12.17 g/dL in the US). Intersurvey variance around the Hb fifth percentile was low (3.5% for women and 3.6% for children). Pooled fifth percentile estimates were 9.65 g/dL (95% CI, 9.26-10.04 g/dL) for children and 10.81 g/dL (95% CI, 10.35-11.27 g/dL) for women. The Hb-for-sTfR curve demonstrated curvilinear associations with sTfR inflection points occurring at Hb of 9.61 g/dL (95% CI, 9.55-9.67 g/dL) among children and 11.01 g/dL (95% CI, 10.95-11.09 g/dL) among women.

Conclusions and relevance: Current WHO cutoffs to define anemia are higher than the pooled fifth percentile of Hb among persons who are outwardly healthy and from nearly all survey-specific estimates. The lower proposed Hb cutoffs are statistically significant but also reflect compensatory increased erythropoiesis. More studies based on clinical outcomes could further confirm the validity of these Hb cutoffs for anemia.

Publication types

  • Evaluation Study

MeSH terms

  • Adolescent
  • Adult
  • Anemia / diagnosis*
  • Biomarkers / blood
  • C-Reactive Protein / analysis
  • Child, Preschool
  • Cross-Sectional Studies
  • Erythropoiesis
  • Family Characteristics
  • Female
  • Ferritins / blood
  • Global Health / statistics & numerical data*
  • Hemoglobins / analysis*
  • Humans
  • Infant
  • Iron Deficiencies / diagnosis
  • Male
  • Middle Aged
  • Nutrition Surveys
  • Population Health / statistics & numerical data*
  • Reference Values
  • Retinol-Binding Proteins / analysis
  • Vitamin A / blood
  • Vitamin A Deficiency / diagnosis
  • World Health Organization
  • Young Adult


  • Biomarkers
  • Hemoglobins
  • Retinol-Binding Proteins
  • Vitamin A
  • C-Reactive Protein
  • Ferritins