Prevalence of Iron Deficiency and Health-related
Quality of Life among Female Students
Marie-Ange Grondin, MD, Marc Ruivard, MD, Anne Perre `ve, MD, He ´le `ne Derumeaux-Burel, MD, Isabelle Perthus, MD,
Julie Roblin, BSc, Fabrice Thiollie `res, MD, Laurent Gerbaud, MD, PhD
Centre Hospitalo Universitaire de Clermont-Ferrand (M.-A.G., M.R., H.D.-B., I.P., J.R., F.T., L.G.), Service de Soins Inter
Universitaire (A.P.), Clermont-Ferrand, FRANCE
Key words: iron deficiency, prevalence, quality of life, general health, SF-36 Questionnaire, female, students
Objective: To investigate prevalence of iron deficiency and examine the relationship between iron status and
Health-related Quality of Life among female students.
Design: Cross-sectional study.
Subjects and Setting: Data were collected from 543 female students, aged 17 to 38 years, attending
University or secondary schools in Clermont-Ferrand (France) and its metropolitan area. Three groups were
defined, according to the rate of serum ferritin: iron deficient (serum ferritin ?15?g/L), iron depletion borderline
(serum ferritin 15–20 ?g/L), and iron replete (serum ferritin ? 20 ?g/L). Those 3 groups of menstruating female
students were compared in terms of health-related quality of life using univariate analysis.
Measures of Outcome: Health-related Quality of Life based on SF-36 questionnaire, and iron status
measured by serum ferritin.
Results: The prevalence of iron deficiency was 19.3 %, the prevalence of borderline iron status was 11.4 %.
Regarding the SF-36 questionnaire, the only significant difference between iron deficient and iron replete female
students concerned the dimension reflecting ‘general health’, which was significantly lower in iron deficient
group (p ? 0.015).
Conclusion: Iron deficiency seems to impair the perceived general health in female students. Further
research should be conducted on this little known subject.
Iron deficiency is one of the most common nutritional
disorders in industrialised countries, especially in menstruating
women and adolescents . In France, the prevalence of iron
deficiency anaemia was estimated to be about 2.0 % in men-
struating women and 10.0 % in pregnant women [2,3]. The last
data from the French cohort SU.VI.MAX. (SUpplementation
en VItamines et MIneraux)  assessed a prevalence of iron
depleted stores in menstruating women (aged 35 to 50 years) of
22.7 %. Anaemia was found in 4.4 % of these women in the
same study. Recently, the functional consequences of iron
deficiency among women of childbearing age were reviewed
. These functional consequences include impaired physical
work capacity (such as aerobic fitness, endurance capacity,
work efficiency, fatigue and voluntary activity), deficits in
cognitive function and mood (such as short-term memory,
verbal learning, attention span/concentration, intelligence, de-
pressive symptoms) and reduced immune function. But still
little is known about the links between iron deficiency and
general health, well-being, normal day-to-day functioning
[6,7]. A worsened quality of life is often described for anaemia
or iron-deficiency as a consequence of chronic pathologies
such as cancer or chronic renal diseases (1356 articles cited in
PubMed for “quality of life AND anaemia”). But few studies
use an objective tool of measure to assess quality of life, and
Address correspondence to: Dr Marie-Ange Grondin, De ´partement de Sante ´ Publique, Ho ˆtel-Dieu, Boulevard Le ´on-Malfreyt, 63058 Clermont-Ferrand, France. E-mail
Abbreviations: FERUNIV ? iron at the university study, MCS ? SF-36 mental component summary score, PCS ? SF-36 physical component summary score, SF ? Serum
Ferritin, SF-36 ? Medical Outcome Study Short Form 36 item, SSIU ? Inter University Health Care Service, SU.VI.MAX ? SUpplementation en VItamines et MIneraux
Journal of the American College of Nutrition, Vol, 27, No. 2, 337–341 (2008)
Published by the American College of Nutrition
less study the most common iron deficiency seen in menstru-
ating women, related to nutrition and iron loss [8,9].
Our study, named FERUNIV (iron at the university, in
French) had two parts. The first part intended to assess the iron
deficiency prevalence and its consequences on health related
quality of life. The second part intended to compare the effects
of iron supplementation daily or twice a week on iron deficient
female students . This population was chosen since iron
deficiency is frequently observed in it, due to puberty, men-
strual losses and limited dietary iron intake . The study was
initiated by the INRA (National Institute of Agronomic Re-
search). In the first part of this study, the screening of the iron
status of female students was made with the help of the SSIU
(Inter University Health Care Service) of Clermont-Ferrand. The
SSIU has for mission to study and improve students’ health. It
gynaecologists, psychiatrists, to all students. We present the
results of FERUNIV’s first part with 2 different objectives:
- to determine the prevalence of iron deficiency among
- to examine the relationship between iron status and
health-related quality of life.
MATERIALS AND METHODS
The SSIU of Clermont-Ferrand (France) offers about 10 000
health consulting per year. The sex ratio (male/female) is
estimated at 0.55. Every female student at the university or at
the secondary schools in Clermont-Ferrand consulting a phy-
sician of the SSIU at Clermont-Ferrand was informed of the
study. There also was advertising of the study in schools and
university halls and in the local media (newspaper, radio).
Students accepting the study had to give a signed consent. They
were proposed the Short-Form 36 health-related quality of life
questionnaire (SF-36) before iron blood sampling, whatever the
consulting reason. This detection was free. Only one detection
was offered to the subjects during the two years study. Only the
female students coming for the screening or benign pathologies
could be included. Consulting for severe pathologies was a
matter of exclusion. The recruitment had to stop once the 25
students included for the second part of the study, that is
treatment of iron deficient female students whether by iron
daily supplementation or twice a week supplementation. The
iron deficient group was treated (supplementary iron intakes)
and followed by a general practitioner of her choice or by the
SSIU physicians. The iron depletion borderline group received
The study was ethically approved by the French CCPPRB
(Comite ´ Consultatif de Protection des Personnes dans la Re-
cherche Biome ´dicale, Consultative Committee for Persons Pro-
tection in Biomedical Research).
The SF-36 questionnaire is an objective validated question-
naire used to assess the level of health-related quality of life.
The French version of SF-36 was cross-cultural translated and
validated [12,13]. French population reference values for this
instrument are published . It includes 8 dimensions of
health-related quality of life: physical functioning, role limita-
tions due to physical problems, mental health, vitality, role
limitations due to emotional problems, social functioning,
bodily pain, and general health. Two summary scores are
described: the physical component summary (PCS) and the
mental component summary (MCS). Scoring techniques are
those published in the first publication . The scores vary
from 0 to 100: from the worse to the best health-related quality
All blood samples were sent to the same laboratory. We
used serum ferritin as a marker of iron stores, since serum
ferritin has been proved to have a high specificity, powerful
enough for the diagnosis of iron-deficiency-anaemia , es-
pecially with low values. Results of ferritin rates, after two
measurements defined three groups:
- Iron deficiency for serum ferritin ?15?g/L,
- Iron depletion borderline for serum ferritin between 15
and 20 ?g/L,
- Iron repletion for serum ferritin ? 20?g/l.
To investigate further the analysis, we considered alternatively
that borderline iron status could be associated to iron deficient
or to iron replete results. The most consistent results were
obtained by associating the borderline group to the iron replete
ANOVA or Kruskal-Wallis tests (when distributions were
not normal) were used to compare means scores of the SF-36
questionnaire between the three or two groups defined by
serum ferritin rates. Mean scores of this study were then com-
pared to the French population reference values.
The first part of FERUNIV was performed from November
2000 to September 2002 in the three consulting physicians’
sites of the SSIU in Clermont-Ferrand.
A total of 543 female volunteered. The age range of the
subjects was 17 to 38 years with a mean of 21.4 (SD 2.4) years,
not varying with iron status.
The iron status, defined by Serum Ferritin (SF) level, was
assessed (Table 1). The iron-deficient group (SF ?15?g/L)
Fe and Health-Related Quality of Life
338VOL, 27, NO. 2
represented 19.3% of the studied population. Only 29 female
students of this iron deficient group were then followed by a
SSIU physician, and 10 on them were anaemic.
The answering exhaustivity and mean scores of SF-36 di-
mensions are described in Table 2. The answering exhaustivity
of the questionnaire varied from 92.6 to 95.4 %. The compar-
isons of SF-36 mean scores between the 3 iron status groups
were first analysed (Table 3). The only significant difference of
mean scores of quality of life between the 3 iron status groups
was found in general health dimension: 65.3 for the iron replete
group versus 60.7 for the iron deplete group (p ? 0.028). This
difference stayed significant when the borderline iron status
group was associated with the replete iron status group: 65.7 for
this new group versus 60.7 for the deficient iron status group
(p ? 0.015).
The comparisons of FERUNIV population SF-36 mean
scores with the French population reference values were then
analysed (Table 3, second column). Whatever the dimension,
the mean scores of FERUNIV female students were signifi-
cantly lower (p ? 0.05) than the French population reference
values (females aged 18 to 24 years old).
FERUNIV study has permitted answer to its objectives:
- to determine the iron deficiency prevalence in female
students: estimated at 19.3 %,
- to study the links between iron deficiency and health
related quality of life: it found a link between iron status
and the perceived general health.
Iron Deficiency Prevalence
The iron deficiency prevalence found in FERUNIV study
(19.3 %) is congruent to bibliography results. Iron deficiency
affects 20 to 50 % of the world’s population . In the United
States, it affects at least 9–11 % of adolescent girls and women
of child-bearing age , not forgetting that it can increase 4
times with poverty . In Australia, it affects at least 8 % of
women . In Europe, the prevalence of iron deficiency is
estimated between 8 and 33 % of young women [17,18].
Recent French studies found 22.7 % of iron-deficient menstru-
ating women .
Links Between Iron Deficiency, General Health and
Health-Related Quality of Life
This study brings new material to health-related quality of
life approach and iron deficiency. Considering general health,
Mansson found a significant relation between iron deficiency
and vertigo/dizziness with a “standardized questionnaire of 30
questions related to quality of life” . Verdon observed a
relation between the level of fatigue perceived by patients
assessed on a visual analogue scale, and iron deficiency .
This fatigue improved with iron supplementation. Analysing
the results of the only studies which used a validated scale of
quality of life, Anna Rangan examined the relationship between
iron status and non specific symptoms among female students,
measuring psychological distress with the General Health
Questionnaire . She found no relation, except for anaemic
subjects. Fordy and Benton didn’t find any relation at all, with
the same questionnaire . Patterson studied the effects of
iron deficiency and its treatment by iron supplementation or a
high iron diet on fatigue and general health measures in women
of childbearing age, measuring these parameters with the Piper
Fatigue Scale and the SF-36 General Health and well-being
questionnaire . She found a link between iron deficiency and
reduced general health and well-being: iron deficient women
had lower scores in the dimensions of mental component sum-
mary (reminding that the mental component summary is cal-
culated with all the weighted dimensions) and vitality. Both
scores improved with supplement iron treatment. The limit
pointed by the author was that women were aware of their iron
status at the time that they completed the questionnaires (even
though it’s difficult for patients to distinguish the items related
to the different scores), which is not the case in our study.
Duport, with the SU.VI.MAX. cohort in France studied the
relation between iron deficiency and quality of life measured
with the Duke profile . The lower trends for physical health
and perceived health associated to iron deficiency weren’t
statistically significant. The synthesis of all these studies seems
to point a relation between iron deficiency and general health,
as observed in our study. One difficulty lies in a standardized
Table 2. Exhaustivity and Mean Scores of SF-36
Dimensions Answered by the French Female Students in
Table 1. Prevalence of Iron Deficiency in 17 to 38 Years
Old French Female Students
Serum Ferritin level
Iron depletion borderline
SF ? 15?g/L
15 ? SF ? 20?g/L
SF ? 20?g/L
Fe and Health-Related Quality of Life
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION339
definition of this general health. Using the validated SF-36
questionnaire permits to solve this difficulty. Another comment
must be made about the measure of serum ferritin to assess iron
deficiency. Cook recalls that serum ferritin low values identify
iron deficiency anaemia unequivocally . Serum ferritin
results are specific  but not sensitive. This could be another
reason why the link between general health and iron deficiency
is difficult to prove. The specificity of serum ferritin in iron
deficiency seems to be proven in Feruniv study. In the fol-
low-up of this study, on the 66 students who came back after
the letter informing them that they presented a low serum
ferritin, 27 gave consent to be included in the supplementation
study. On these 27, a second blood sample was analysed: a
normal ferritin concentration was found in only one student.
The ferritin concentration could be falsely normal in the
case of anaemia of chronic disease or thalassaemia or even
carousing. The anaemia of chronic diseases or thalassaemia
increases serum ferritin (by inflammatory process). These ill-
nesses would match normal serum ferritin, but related to a
worsened quality of life, leading to mask the real link between
the reduced serum ferritin concentration and low SF36 scores.
However, chronic inflammatory illnesses are rare among stu-
dents. Female students coming with explicit symptoms were
examined and treated, not corresponding to those screened.
Serum ferritin increase due to carousing (due to alcohol)
and having a link with health-related quality of life is not
known. All French female students are not binge drinkers.
Anyway, female students with binge-drinking consequences
wouldn’t have been included in the screening process. The
possible after-effects of carousing can thus be rejected.
Comparisons to Reference Values
Compared to females aged 18–24 years old French refer-
ence values, the mean scores of our study are significantly
lower. But the French reference population includes only 188
females aged 18–24 years old, versus 543 in FERUNIV study.
The first study conducted in the relatively same conditions by
the SSIU took place in Clermont-Ferrand (France) in 2000 .
It permitted to distinguish healthy patients coming for preven-
tion consultations and students coming for benign pathologies,
which wasn’t possible with FERUNIV design. In this first
SSIU study, the mean scores of students coming for benign
pathologies were significantly lower for the next dimensions:
physical functioning, role limitations due to physical problems,
vitality, mental health, social functioning, and bodily pain. We
can’t exclude the possibility that in FERUNIV study students
came mostly for benign pathologies rather than for prevention
consultations, especially since the whole profile of SF-36 mean
scores in FERUNIV looks rather like the one coming for
benign pathologies in the first study. In that case, the power of
statistical tests could be reduced and could ignore other links
between other SF-36 dimensions and iron deficiency. But this
doesn’t suppress the information that general perceived health
is affected by iron deficiency.
Paths to Future Research
In the future, new designs could be imagined to improve the
knowledge in the field of health related quality of life and iron
deficiency. For example, the female students included in that
kind of study should exclusively be diagnosed and treated in
the same place, so that anaemia prevalence could be inter-
preted. In our study, 10 (2.0 % of the total) female students
were anaemic, but this diagnosis was only made on female
students first screened positive for iron deficiency, and sec-
ondly treated by the SSIU. All students diagnosed or treated
elsewhere couldn’t be counted. Another improvement could be
made by noting the kind of consultation (prevention or benign
pathology). Last, it would be important to follow the results of
SF-36 mean scores after iron supplementation.
Iron deficiency was screened in 543 female students in a
cross-sectional study named FERUNIV in Clermont-Ferrand
Table 3. Comparisons of SF-36 Mean Scores between FERUNIV Study (by Iron Status Defined Groups) and the French Young
Female Reference Population
French females (aged 18–24)
* p ? 0.028
Fe and Health-Related Quality of Life
340VOL, 27, NO. 2
(France). Of this population, the prevalence of iron deficiency
was 19.3 % (serum ferritin ?15 ?g/L), the prevalence of
borderline iron status (serum ferritin between 15 and 20 ?g/L)
was 11.4 %. The link between iron deficiency and health-
related quality of life was analysed, with the SF-36 question-
naire. The only link was found between iron deficiency and one
dimension of the SF-36 questionnaire: perceived general
health. Giving the conflicting results of the main few studies on
this subject, more studies are required to improve knowledge in
the field of health-related quality of life and iron deficiency.
Thanks to the contribution of all the physicians and nurses
who included the female students to the study. Thanks to all the
female students who gave their informed consent to the study.
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