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Author Notes:

Corresponding Author: zam0@cdc.gov

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

We acknowledge the contributions of the BRINDA steering committee [GJ Aaron, RF-A, SMLN, DJR, and PSS (chair)] and the BRINDA working group (OYA, Deena Alasfour, Fayrouz A Sakr Ashour, Zulfiqar Bhutta, Reina Engle-Stone, Roland Kupka, Leila M Larson, Nino Lortkipanidze, Barbara MacDonald, Purnima Menon, Rebecca Merrill, ZM, Christine A Northrop-Clewes, Pura Rayco-Solon, Rahul Rawat, FR, Ofelia P Saniel, Olga L Sarmiento, MS, Saleh Al Shammakhi, Victor Temple, Andres B Tschannen, Anne Williams, and James P Wirth).

For individual contributions see the PMC version of the article.



  • Science & Technology
  • Life Sciences & Biomedicine
  • Nutrition & Dietetics
  • acute-phase proteins
  • C-reactive protein
  • ferritin
  • inflammation
  • iron deficiency
  • preschool-age children
  • soluble transferrin receptor
  • total body iron
  • women of reproductive age
  • alpha-1-acid glycoprotein

Adjusting total body iron for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project


Journal Title:

American Journal of Clinical Nutrition


Volume 106, Number 1


, Pages 383S-389S

Type of Work:

Article | Final Publisher PDF


Background: Total body iron (TBI) that is calculated from ferritin and soluble transferrin receptor (sTfR) allows for the evaluation of the full range of iron status from deficiency to excess. However, both ferritin and sTfR are affected by inflammation and malaria, which may require a statistical adjustment. TBI has been used to assess iron status in the United States, but its use worldwide and in settings with inflammation has been limited.Objective: We examine whether inflammation-adjusted ferritin and sTfR concentrations affect TBI values and the prevalence of low TBI ( < 0 mg/kg) in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y).Design: Cross-sectional data for PSC (8 surveys; n = 8413) and WRA (4 surveys; n = 4258) from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined. TBI and the prevalence of low TBI were compared following 3 adjustment approaches for ferritin and sTfR: 1) the exclusion of individuals with inflammation (C-reactive protein concentration > 5 mg/L or α-1-acid glycoprotein concentration > 1 g/L), 2) the application of arithmetic correction factors, and 3) the use of regression correction.Results: Regardless of the method that was used to adjust ferritin and sTfR for inflammation, the adjusted mean TBI decreased in both PSC and WRA compared with unadjusted values. Subsequently, inflammation-adjusted TBI increased the prevalence of low TBI by a median of 4-14 percentage points (pps) in PSC and 1-3 pps in WRA compared with unadjusted TBI. The regression approach resulted in a greater median increase than was achieved with the exclusion or correction-factor approaches, and accounting for malaria in addition to inflammation did not have an added effect on the prevalence estimates.Conclusion: The prevalence of low TBI is underestimated if it is not adjusted by inflammation, particularly in children living in areas with a high prevalence of inflammation.

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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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