Can anemia cause blood sugar problems?

Anemia can cause sugar problems, but  the connection is not “a real” connection, it arises because of the way sugar problems are typically tracked.  Ignoring this can have dire consequences.

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Anemia can cause sugar problems –   INDIRECTLY

red blood cells in trouble thanks to anemia

Anemia can cause sugar problems but the connection is not “a real” connection, it arises because of the way sugar problems are typically tracked. Ignoring this can have dire consequences.

On paper, red blood cells are red blood cells and sugar is sugar, and never the twain shall meet.

But the two do intersect in the HbA1c test.

This is a test that is routinely used to keep tabs on glycemic control.

The overlap, means that anemia can cause blood sugar problems, because anemia impacts your HbA1c numbers.

NOTE : Any time your HbA1c number bumps up, to more than 6,5 %, you’re diagnosed with type 2 diabetes.

But the relationship is not straight forward…..

The red blood cell factory

To begin to unpack this complex relationship we need to inspect one of the dozens of factories, dotted around the body, producing red blood cells.  They’re hives of activity, churning out astronomical numbers of cells each day.

NOTE :  It is estimated that 2.4 million red blood cells are made EVERY SECOND. 

There activities are highly regulated.

And quite unexpectedly the organ that is making ALL the decisions, is the kidney, because the kidney is exquisitely sensitivity to overall oxygen levels.

I need more oxygen – PLEASE !

an oxygen starved kidney dispatching EPOA drop in oxygen content triggers cells in the kidney to release the hormone erythropoietin or EPO, for short. EPO travels to the bone marrow, where she whips the erythroblasts, the cells responsible for making red blood cells, into shape.

The erythroblasts start dividing in earnest.

But, since red blood cells are  essentially “bags of haemoglobin” – the newly minted red blood cells, need to be filled up with haemoglobin.

Iron is the cherry on top

The cells usually have  no problem assembling the globin part of the haemoglobin. But, iron molecules which are needed to put the “cherry on the top” of the globin and turn it into hemo-globin, are outsourced.

erythroblasts making hemoglobin

So erythroblasts require large amounts of iron.

The cells dispatch erythroferrone to negotiate with the liver, for  sufficient iron resources.

Iron is normally safely locked away

On paper at least, the appeal for iron is easy to service, since the liver, as part of day to day operations, collects iron from the diet and stores it in ferritin for such occasions, but this iron is locked away.

Because  iron DOES chemistry.

And allowing iron to willy nillly circulate, would be  a recipe for disaster.

Getting the iron circulating

Now the iron lock down, depends on the activities of hepcidin, a protege of the liver.  Hepcidin keeps the iron out of circulation by “taking out” the only known iron export pump, ferriportin.

hepcidin taking out the iron export pump

Errythroferrone petitions the liver to release iron stores.

Explaining the difficulties erythroblasts are experiencing with the current shortages.

A flood of iron is unleashed

 The liver happily obliges, ordering hepcidin to stand down.

And iron begins to flow……….

Not only from the liver, but also from macrophages.

Red blood production humming along nicely

With hepcidin levels down, the erythroblasts in the bone marrow, have all the iron they need, to finish the job of making and loading up,  brand new red blood cells. The newly minted red blood cells,   roll off the assembly line, whizz through the lungs, to pick up their first consignment of oxygen and then travel round and round, making deliveries.

Until they get too old and long in the teeth.

spleen measuring up an old red blood cell

It’s a short productive life

They then check out and are loving embalmed by the spleenic macrophages.  To preserve the precious iron contained with the bodies of the dearly departed red blood cells, the attending macrophages….

macrophage gathering the iron from a red blood cell corpse

They will hold on to it, until they get the all clear from the liver.

This is signalled by the drop in hepcidin levels.

The system is perfect

Exactly the right number of red blood cells are made and loaded up with haemoglobin to meet oxygen demand.


The iron stores are LOW.

problems with iron stores

The iron stores may genuinely be low, but sometimes the low iron is as a result of extenuating circumstances. Inflammation and hyperinsulinemia, can keep the iron locked away, creating a  functional iron deficiency, in the midst of plenty.

Low iron causes trouble with a capital T

When the erythroblasts run out of iron –  they are forced to make  adjustments to red blood cell production.

  • Sometimes they continue to send out red blood cells, but send them out, with less haemoglobin, than ideal.
  • If things are really bad, they go to half time, diminishing the production of red blood cells.

These changes are reflected in blood work numbers :

  • Hemoglobin levels are lower than normal.
  • Red blood cell counts and haematocrit are also diminished.

sample blood work from someone with anemia

The anemia causes a sugar problem

When the levels cross a threshold………….. anemia is diagnosed and more often than not,  you feel as flat as a pancake, because cells across the body, suffer from oxygen shortages.

But the low haemoglobin is what creates the “sugar problem”.

Because when the number of haemoglobin molecules is diminished, the  odds that a haemoglobin  molecule that is looked at, is glycated sky rockets, so ………..

someone with iron deficiency anemia being diagnosed with diabetes

Iron deficiency anaemia gets flagged as a sugar problem,

when there isn’t a sugar problem per se.

Anemia hides a sugar problem

But this is NOT what happens, in all anemias, for example in the haemolytic anemias the red blood cells are weak and vulnerable.

They tend to die young.

Sometimes it’s all very civilized, often times it’s NOT.

Their absence is noted by the kidney, EPO is dispatched and red cell production is initiated.

Since there is no shortage of iron, the red blood cells leave FULLY LOADED and begin their mission of supplying oxygen to  EVERYONE.

Hemoglobin levels not really low

The point is……..there is no inherent shortage of haemoglobin, it might not be inside the red blood cell, but it has been in circulation.

Glycation opportunities existed.

the missing glycated hemoglobin not being counted

Left, right and centre.

But when the red blood cell lyses, the glycated haemoglobin disappears  –  without a trace, leaving the  HbA1c count  lower than expected. Because of the  limitations of the HbA1c test :

Hemolytic anemias hide sugar problems.

i.e. the anemia causes a sugar problem that is not noticed (under diagnosis)

Anemia can cause “sugar problems” INDIRECTLY

If you are struggling with anemia, don’t rely solely on the HbA1c test to keep tabs on your glycemic status, check your sugar level directly.

And be aware – the cause of the anemia matters.

NOTE : Iron is both necessary and toxic, so only supplement with iron if you are genuinely deficient. Be very weary of using an iron supplement as an insurance policy.  Insulin is impacting your iron biology and too much iron can cause diabetes (this is what happens in people who suffer from hemochromatosis)

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A Red Carpet for Iron Metabolism. Cell. (2017) 168(3): 344–361.  Martina U. Muckenthaler, Stefano Rivella, Matthias W. Hentze, and Bruno Galy.

Effect of iron deficiency anemia and iron supplementation on HbA1c levels – Implications for diagnosis of prediabetes and diabetes mellitus in Asian Indians.  S.V. Madhu, Abhishek Raj, Stuti Gupta, S. Giri, Usha Rusia

The effect of anaemia and abnormalities of erythrocyte indices on HbA1c analysis: a systematic review. Diabetologia (2015) 58:1409–1421. Emma English, Iskandar Idris, Georgina Smith, Ketan Dhatariya, Eric S. Kilpatrick W. Garry John

Further reading


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Author: Taylor Payne