Anemia and Diabetes: Understanding the Critical Connection

Explore the complex link between anemia and diabetes, including symptoms, diagnosis, causes, and effective treatments.

By Medha deb

Created on Sep 25, 2025

Explore the complex link between anemia and diabetes, including symptoms, diagnosis, causes, and effective treatments.

Living with diabetes involves managing a complex array of symptoms and health risks, but one potentially overlooked concern is anemia. While neither condition directly causes the other, their intersection can have far-reaching effects on health. This article explores how anemia and diabetes relate, mutual risk factors, how complications develop, and what you can do to manage both conditions effectively.

While diabetes does not directly cause anemia, and anemia does not directly cause diabetes, research shows a significant overlap between the two conditions. Up to 25% of Americans with type 2 diabetes also have anemia. This means it is quite common for individuals managing diabetes — particularly those with diabetes-related complications — to also experience anemia.

Anemia affects the number of healthy red blood cells or the amount of hemoglobin available to deliver oxygen to the body’s tissues.
Having one of these conditions does not automatically result in the other, yet their coexistence can worsen overall health and complications.

Why Are People with Diabetes at Risk for Anemia?

Several diabetes complications can contribute to the development of anemia. Understanding these connections can help patients and care teams spot problems early:

Chronic Kidney Disease: Damaged kidneys from diabetes may stop producing enough erythropoietin (EPO), the hormone that signals bone marrow to make red blood cells.
Inflammation: Diabetes is often linked with chronic inflammation, which can further impair EPO signaling and disrupt red blood cell production.
Blood Vessel Damage: Inflamed blood vessels common in diabetes can prevent effective delivery of EPO signals to the bone marrow, worsening anemia risks.
Other Factors: Poor nutritional absorption, medication side effects (such as from metformin), and chronic blood loss may also play roles.

Symptoms of Anemia in Diabetes

The symptoms of anemia can be subtle at first, particularly in people already dealing with diabetes complications. Some key symptoms to monitor include:

Chronic fatigue or weakness
Pale or yellowish skin
Shortness of breath, especially during normal activities
Rapid or irregular heartbeat
Frequent headaches or dizziness
Cold hands and feet
Chest pain or unexplained lightheadedness

It’s important to discuss these symptoms with your healthcare provider, especially if you already have a diabetes diagnosis, as anemia can intensify diabetes complications.

Diabetes Complications That Contribute to Anemia

Kidney Disease (Diabetic Nephropathy)

Kidney disease is a leading factor linking diabetes and anemia. Healthy kidneys filter waste from the blood and produce erythropoietin. When diabetes damages the kidneys (even in early, asymptomatic stages), they lose their ability to make adequate EPO, causing a decrease in red blood cell production and resulting in anemia.

The early stages of diabetic nephropathy may have no clear symptoms, but anemia can be a warning sign of deeper kidney dysfunction.
Kidney issues from diabetes can create a cycle where worsening anemia damages tissues further, advancing vascular and organ complications.

Vascular and Nerve Damage

Chronic high blood glucose can damage blood vessels and nerves. Inflamed blood vessels limit the body’s ability to create new red blood cells, and chronic inflammation also increases cytokine production, which suppresses erythropoiesis (red blood cell formation). This can impair blood flow and oxygenation to tissues, feeding into a worsening cycle of diabetic complications.

Other Complications

Retinopathy: Anemia worsens eye complications in diabetes, contributing to vision loss.
Neuropathy: Nerve damage may be aggravated by the lack of oxygen supply, as seen in anemia.
Heart Disease: Reduced oxygen-carrying capacity puts additional stress on the heart, which is already at risk in diabetic individuals.
Non-healing Ulcers: Poor oxygen supply hinders wound healing, especially in the lower limbs and feet — resulting in persistent ulcers and increased infection risks.

How Does Anemia Affect Blood Sugar Levels?

The interplay between anemia and diabetes doesn’t only exacerbate complications — it can also lead to misleading readings on standard blood sugar tests and tricky management situations.

False High Glucose Readings: Anemia, especially when caused by iron deficiency, can cause glucose meters to display artificially high blood sugar readings, leading some patients to overtreat and potentially trigger dangerous hypoglycemia.
HbA1c Complications: Studies indicate that in both people with and without diabetes, iron-deficiency anemia can cause increased A1C test results. This is due to more glucose molecules sticking to fewer available red blood cells, skewing average blood sugar assessments. After iron supplementation or treatment for anemia, A1C levels tend to drop.

Causes of Anemia in People with Diabetes

Anemia in the context of diabetes can be multifactorial. The main causes include:

Cause	Explanation
Kidney damage (CKD)	Reduced EPO production, decreasing red blood cell formation
Chronic inflammation	Cytokine-induced suppression of bone marrow activity
Medication effects (e.g., metformin)	May cause vitamin B12 deficiency and decrease iron absorption
Poor nutrition/malabsorption	Deficiencies in iron, vitamin B12, and folate
Blood loss	Frequent in those with gastrointestinal complications from diabetes

It’s important for healthcare teams to investigate and identify the primary cause of anemia in each person with diabetes to guide effective treatment.

Diagnosing Anemia in People with Diabetes

If you have diabetes and experience symptoms associated with anemia — or if you have kidney impairment — your clinician may order several tests:

Complete Blood Count (CBC): Measures hemoglobin, hematocrit, and red blood cell counts.
Iron Studies: Include serum ferritin, transferrin saturation, total iron binding capacity (TIBC), and serum iron levels.
Tests for Vitamin B12 and Folate: To check for nutritional causes of anemia.
Kidney Function Tests: Such as glomerular filtration rate (GFR), serum creatinine, and urine albumin.
Additional work-up: May include looking for sources of internal bleeding or bone marrow dysfunction if necessary.

It’s advisable for people with diabetes to undergo regular screening for anemia, especially if they have risk factors like prolonged diabetes, kidney disease, or poor glycemic control.

Prevalence of Anemia in Type 2 Diabetes

Research highlights the significant prevalence of anemia among people with type 2 diabetes.

An estimated 20% of individuals with type 2 diabetes globally experience anemia.
Prevalence can be higher in some populations due to varying access to healthcare, nutritional status, and frequency of diabetes complications:

20% in Australia
46.5% in Caribbean populations
41.7–63% in Pakistan
29.8% in Ethiopia
63% in Egypt

Most anemia cases in diabetes are mild and classified as normocytic normochromic, meaning the size and color of the blood cells remain normal, but their overall number is reduced.

Risk Factors for Anemia in Diabetes

Long duration of diabetes (especially more than 10 years)
Poor glycemic (blood sugar) control
Decreased kidney function
Diabetes-related macrovascular (large vessel) or microvascular (small vessel) complications
Age over 60 years

Being aware of these risk factors empowers people with diabetes to seek timely evaluation and intervention.

Managing and Treating Anemia with Diabetes

Treatment for anemia in people with diabetes is tailored to the underlying cause, severity, and the patient’s overall health. Common management strategies include:

Dietary and Supplementation Approaches:
- Increasing intake of iron-rich foods (e.g., beans, lentils, leafy green veggies, oysters, tofu, red meat, fish, liver, dried fruits like prunes or raisins).
- Taking oral iron supplements, and, if needed, vitamin B12 or folic acid supplements.
Addressing Medication-Induced Anemia:
- Certain diabetes drugs (notably metformin) may contribute to vitamin B12 deficiency. If this is the case, your doctor may recommend a switch in medication or supplementation.
Kidney Disease Management:
- If you are on dialysis, intravenous iron or erythropoiesis-stimulating agents (like synthetic EPO) may be required. Note that 5–10% of patients receiving synthetic EPO can develop resistance, in which case careful monitoring and adjustments are essential.
Blood Transfusions: In rare, severe cases, blood transfusions may be necessary, especially if anemia is caused by blood loss.
Multidisciplinary Approach: Coordination between endocrinologists, nephrologists, dietitians, and primary care providers can provide the best outcomes.

Treating the underlying cause is crucial: iron-deficiency, vitamin B12 deficiency, chronic disease, or blood loss all require tailored interventions for best results.

Lifestyle and Self-Care Strategies

There are important steps people with diabetes can take to lower their risk and mitigate the effects of anemia:

Maintain regular medical check-ups to detect complications early.
Eat a varied, balanced diet rich in iron, vitamins, and minerals. Pay particular attention to animal or plant sources of iron and foods high in vitamin C to improve iron absorption.
If prescribed metformin, ask your doctor for periodic vitamin B12 level checks.
Manage blood sugar tightly to minimize damage to kidneys and blood vessels.
Stay hydrated and physically active where medically safe.

When to See Your Doctor

If you have diabetes and experience persistent fatigue, weakness, chest pain, or unexplained shortness of breath, contact your healthcare provider immediately. These may be signs of worsening anemia or emerging diabetes complications. Routine screening for anemia can be crucial, especially with a long history of diabetes or known kidney impairment.

Frequently Asked Questions (FAQs)

Q: Does anemia cause diabetes or vice versa?

A: No, neither condition causes the other directly. They commonly coexist because diabetes complications, like kidney disease, can increase anemia risk, and anemia can worsen the health burden in people with diabetes.

Q: What is the most common type of anemia in diabetes?

A: Normocytic normochromic anemia is most common in diabetes. It is usually related to chronic disease, often as a result of impaired kidney function.

Q: How often should I be screened for anemia if I have diabetes?

A: Experts recommend annual screening, or more frequently if you have kidney problems, persistent fatigue, or changes in your diabetes management needs.

Q: Can anemia affect my diabetes blood sugar tests?

A: Yes. Anemia, particularly iron deficiency, can falsely elevate glucose meter and HbA1c readings, making blood sugar management challenging.

Q: What lifestyle changes can help reduce anemia risk in diabetes?

A: A balanced diet rich in iron and B vitamins, regular exercise, good hydration, medication review, and regular doctor visits help lower anemia risk and improve outcomes.

Key Takeaways

Up to 1 in 4 people with type 2 diabetes may also have anemia.
The overlap is most often due to diabetes-related kidney or vascular complications.
Anemia in diabetes can worsen fatigue, aggravate complications, and mislead blood sugar testing.
Effective management is tailored to the root cause and includes dietary changes, supplements, medications, and, in severe cases, blood transfusions.
Regular screenings and a proactive approach are crucial for early detection and optimal care.

References

Author

medha deb

Medha Deb is an editor with a master's degree in Applied Linguistics from the University of Hyderabad. She believes that her qualification has helped her develop a deep understanding of language and its application in various contexts.

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