Feature Articles

Recognizing Anemia in People with Diabetes

March 11, 2009

Glucose meter

What causes anemia in people with diabetes?

  • When diabetes affects your kidneys (diabetic nephropathy), they may not be able to produce enough erythropoietin, a hormone that controls the production of red blood cells.3 Since your red blood cells carry oxygen, having fewer red blood cells means your body’s organs may not get enough oxygen. This lack of oxygen produces the symptoms you may feel when suffering from anemia, which are described in detail below.
  • Diabetic nephropathy may affect the way your body responds to anemia.4 Normally, when anemia develops, your body will try to correct it by increasing its production of erythropoietin in order to make more red blood cells. When diabetes affects your kidneys, your body many not be able to increase the production of erythropoietin in response to anemia.
  • Dr. McGill stressed that, “People with diabetes often have nutritional deficiencies which may or may not be directly caused by diabetes, but often can result in anemia.”
    Causes of Anemia for Diabetics
    • Diabetic nephropathy reduces production of erythropoietin
    • Diabetic neuropathy affects the nervous system's anemia response
    • Nutritional deficiencies
    • Medications for related conditions
    People with Type 1 diabetes are at increased risk for other autoimmune disorders such as celiac disease and pernicious anemia (vitamin B12 deficiency) that can cause low blood counts.5 Celiac disease requires a gluten free diet to allow the small intestine to heal. Pernicious anemia cannot be corrected with changes to your diet, but supplements can help correct the anemia that is associated with it. Vitamin B12 may need to be given by injection if the problem is severe.
  • Some medications used to treat diabetes, hypertension and other related conditions may add to the risk of anemia. Diabetes medications called thiazolidinediones (Avandia and Actos) as well as metformin (Glucophage) can increase the risk of developing anemia.6 In particular, metformin may interfere with vitamin B12 absorption, and may lead to a mild B12 deficiency. Dr. McGill suggests that patients who are taking metformin may want to take a multivitamin as well.

What are the symptoms of anemia in diabetes?

Diabetes patients with anemia may feel weak, become tired easily, and have problems carrying out routine activities. Since these symptoms are also symptoms of diabetes, it may be difficult to determine if your symptoms are caused by anemia or by diabetes. Other symptoms of anemia include pale skin, chest pain, irritability, numbness or coldness in the hands and feet, a fast heartbeat, shortness of breath with activity, and headache.

If you’ve been feeling some of these symptoms and think you may have anemia, we recommend you see your healthcare professional. To help you tell your doctor about your symptoms which could be related to anemia, see the anemia Symptoms Quiz for you to fill out and take to your doctor. Dr. McGill quoteClose communication with your doctor will help him or her provide the treatment that is best for you based on what is causing the anemia. According to Dr. McGill, “Doctors and patients can work together to control anemia effectively through medication and lifestyle changes, but continued vigilance and monitoring is necessary.”

What are the effects of untreated anemia in diabetes?

Studies show that having anemia along with diabetes may increase the likelihood of developing diabetic eye disease, developing heart disease or having a stroke.7,8 People who have both diabetes and anemia are more likely to die earlier than those who have diabetes but not anemia.7,8 Fortunately, anemia can be treated, and benefits such as increased energy, activity level and improved quality of life can be achieved.

What treatments are available?

Correction of anemia not only leads to less tiredness, more energy, and an improved quality of life but also to a reduction in mortality and admission to the hospital.9 Studies suggest that treatment of anemia will slow the development of some of the complications of diabetes including damage to the nerves, the eyes and the kidneys.9

Treatment will vary by the cause of the anemia. Iron or vitamin supplements may be recommended. Anemia that is associated with kidney disease may require treatment with drugs called erythropoiesis-stimulating agents (ESAs) that stimulate red blood cell production.

How can I prevent anemia?

Steps to Help Prevent Anemia
  • Control your blood glucose
  • Control your blood pressure
  • Eat recommended amount of iron
  • Get plenty of vitamin C
  • Avoid caffeine

People with diabetes can take steps to decrease their risk of developing anemia. You can help cut the risk of developing anemia by controlling both your blood glucose and your blood pressure.10 Studies have shown that people with very good blood glucose control and high blood pressure control have a lower risk of developing kidney damage. Cutting the risk of kidney disease cuts the risk of anemia.10

A sensible way to help prevent anemia is to eat a nutritious iron-rich diet. Limiting caffeine may also help since caffeine limits iron absorption. Conversely, vitamin C can help your body absorb iron better when taken with iron-rich foods. For tips on healthy eating to prevent anemia, visit the feature articles on Anemia and Nutrition: The Importance of Iron and The Importance of Essential Vitamins.

Most anemias can be prevented or treated by reporting the signs and symptoms to your doctor. Several medications are approved to help correct anemia and we encourage close communication with your doctor.


  1. American Diabetes Association. Total prevalence of diabetes & pre-diabetes Link. Accessed: February 11, 2009.
  2. Thomas MC, MacIsaac RJ, Tsalamandris C, Power D, Jerums G. Unrecognized anemia in patients with diabetes: a cross-sectional survey. Diabetes Care. 2003 Apr;26(4):1164-69. Link.
  3. Bosman DR, Winkler AS, Marsden JT, Macdougall IC, Watkins PJ. Anemia with erythropoietin deficiency occurs early in diabetic nephropathy. Diabetes Care. 2001 Mar;24(3):495-99. Link.
  4. Hadjadj S, Torremocha F, Fanelli A, Brizard A, Bauwens M, Maréchaud R. Erythropoietin-dependent anaemia: a possible complication of diabetic neuropathy. Diabetes Metab. 2001 Jun;27(3):383-85. Link.
  5. De Block CE, De Leeuw IH, Van Gaal LF. Autoimmune gastritis in Type 1 diabetes: a clinically oriented review. J Clin Endocrinol Metab 2008 Feb;93(2):363-71. Link.
  6. Agency for Healthcare Research and Quality. Comparative Effectiveness and Safety of Oral Diabetes Medications for Adults With Type 2 Diabetes. Link. Accessed: February 11, 2009.
  7. Friedman EA, Brown CD, Berman DH. Erythropoietin in diabetic macular edema and renal insufficiency. Am J Kidney Dis. 1995 Jul;26(1):202-08. Link.
  8. Qiao Q, Keinänen-Kiukaanniemi S, Läärä E.. Relationship between hemoglobin levels and diabetic retinopathy. J Clin Epidemiol. 1997 Feb;50(2):153-58. Link.
  9. McGill J, Bell DS. Anemia and the role of erythropoietin in diabetes. J Diabetes Complications. 2006 Jul-Aug;20(4):262-72. Link.
  10. American Diabetes Association. Anemia and Diabetes. Link. Accessed: February 11, 2009.