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Author Notes:

Address correspondence to SMLN (e-mail: sorrelnamaste@gmail.com).

See publication for full list of author contributions.

We thank the BRINDA statisticians Ravi Varadhan and Janet M Peerson for contributing to the statistical approach, as well as Juergen Ehardt, Donnie Whitehead, Kelley Scanlon, Deborah Galuska, David Thurnham, and Sean Lynch for sharing their inputs.

For their contributions, we thank the BRINDA steering committee [Grant J Aaron, RF-A, SMLN, DJR, and PSS (chair)] and the BRINDA working group (O Yaw Addo, Deena Alasfour, Fayrouz A Sakr Ashour, Zulfiqar Bhutta, Reina Engle-Stone, RK, Leila M Larson, Nino Lortkipanidze, Barbara MacDonald, Purnima Menon, Rebecca Merrill, ZM, CAN-C, Pura Rayco-Solon, RR, FR, Ofelia P Saniel, Olga L Sarmiento, Mary Serdula, Saleh Al Shammakhi, Victor Temple, Andres B Tschannen, AMW, and James P Wirth).

None of the authors reported a conflict of interest related to the study.



  • Science & Technology
  • Life Sciences & Biomedicine
  • Nutrition & Dietetics
  • anemia
  • ferritin
  • inflammation
  • iron deficiency
  • meta-analysis
  • nutritional assessment

Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

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Journal Title:

American Journal of Clinical Nutrition


Volume 106, Number 1


, Pages 359S-371S

Type of Work:

Article | Final Publisher PDF


Background: The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation. Objective: We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PS C) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y) and investigated adjustment algorithms to account for these effects. Design: Cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined with the use of a meta-analysis. Several approaches were explored to estimate depleted iron stores (ferritin concentration < 12 μg/L in PSC and < 15 μg/L in WRA) in inflammation and malaria settings as follows: 1) increase ferritin-concentration cutoff to < 30 μg/L; 2) exclude individuals with C-reactive protein (CRP) concentrations > 5 mg/L or α-1-acid glycoprotein (AGP) concentrations > 1 g/L; 3) apply arithmetic correction factors; and 4) use a regression correction approach. Results: Depleted iron-store estimates incrementally increased as CRP and AGP deciles decreased (4% compared with 30%, and 6% compared with 29% from highest compared with lowest CRP deciles for pooled PSC and WRA, respectively, with similar results for AGP). Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7-25 and 2-8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores. Conclusions: Our results lend support for the use of internal regression correction to estimate the prevalence of depleted iron stores in regions with inflammation. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.

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© 2017 by the American Society for Nutrition

This is an Open Access work distributed under the terms of the Creative Commons Attribution 3.0 Unported License (http://creativecommons.org/licenses/by/3.0/).

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