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The definition of anemia: what is the lower limit of normal of the blood hemoglobin concentration?

Ernest Beutler and Jill Waalen

Article Figures & Data

Figures

  • Figure 1.

    A reproduction of the page of the WHO report that has been used as a standard for anemia in epidemiologic studies. The casual treatment of the lower level of normal, given in whole numbers without decimal points in this 40-page document dealing with nutritional anemia, clearly suggests that the authors never intended for these values to become a hallowed international standard. (From Nutritional Anaemias. Report of a WHO Scientific Group. WHO Tech Rep Ser. 1968;405:1-401; with permission.)

  • Figure 2.

    The mean and -1.65 standard deviations of the hemoglobin values of the white subjects in the Scripps-Kaiser and NHANES-III databases after applying the criteria described in the text. The bottom of the error bars represents the hemoglobin value below which only 5% of normal values would be predicted to be present.

Tables

  • Table 1.

    Lower limits of normal of hemoglobin concentration of the blood of adult men and women as assessed by various sources

    SourceMen, g/dLWomen, g/dLPercent normal below cutoffEffect of race
    WHO (Blanc et al1) 13 12 Not provided Not provided
    Jandl3 14.2 12.2 2.5 Discussed
    Williams (Beutler et al4) 14.0 12.3 2.5 Not provided
    Wintrobe (Lee et al5) 13.2 11.6 Not provided Not provided
    Rapaport6 14 12 Not provided Not provided
    Goyette7 13.2 11.7 5 Blacks' hemoglobin 0.5 g/dL lower
    Tietz8 13.2 11.7 Not provided Not provided
    Hoffman et al9 13.5 12.0 2.5 Not provided
    • To convert hemoglobin from grams per deciliter to grams per liter, multiply grams per deciliter by 10.

  • Table 2.

    Mean hemoglobin (g/dL) by sex and age in white and black subjects

    Scripps-KaiserNHANES III
    No.Mean HgbSDNo.Mean HgbSD
    White men, y
       20-29 250 15.43 0.77 332 15.51 0.96
       30-39 894 15.24 0.85 389 15.29 0.95
       40-49 2219 15.20 0.89 379 15.20 0.99
       50-59 3346 15.10 0.93 356 15.17 1.01
       60-69 3073 15.02 0.95 364 14.94 1.04
       70-79 1976 14.75 1.07 315 14.70 1.15
       80+ 466 14.36 1.20 255 14.29 1.31
    White women, y
       20-29 240 13.41 0.80 322 13.57 0.88
       30-39 809 13.59 0.86 402 13.66 0.86
       40-49 1917 13.58 0.86 321 13.58 0.94
       50-59 2829 13.62 0.86 312 13.76 0.94
       60-69 3006 13.63 0.88 320 13.66 1.04
       70-79 2051 13.66 0.94 421 13.68 0.97
       80+ 427 13.54 0.95 342 13.44 1.21
    Black men, y
       20-29 27 14.83 0.76 403 14.84 0.96
       30-39 87 14.76 1.02 394 14.61 1.18
       40-49 163 14.58 1.06 290 14.50 1.07
       50-59 157 14.46 1.08 166 14.25 1.27
       60-69 103 14.27 0.98 137 14.19 1.02
       70+ 32 14.44 1.06 98 13.75 1.15
    Black women, y
       20-29 17 13.26 0.75 321 12.78 0.92
       30-39 68 12.97 0.93 339 12.77 1.11
       40-49 120 12.88 0.91 244 12.87 1.05
       50-59 135 12.96 0.89 146 13.07 0.95
       60-69 90 13.03 0.91 161 12.89 1.01
       70+ 30 12.93 0.88 135 12.65 1.11
    • To convert hemoglobin from grams per deciliter to grams per liter, multiply grams per deciliter by 10.

  • Table 3.

    Lower limits of normal for hemoglobin concentration of the blood in g/dL of younger (age 20-59 for men; 20-49 for women) and older white and black adults

    Scripps-KaiserNHANES-III
    No.2.5% actual2.5% normal distribution5% actual5% normal distributionNo.2.5% actual2.5% normal distribution5% actual5% normal distribution
    White men, y
       20-59 6709 13.4 13.4 13.7 13.7 1456 13.4 13.4 13.8 13.7
       60+ 5515 12.8 12.8 13.2 13.2 934 12.2 12.4 12.8 12.7
    White women, y
       20-49 2966 11.9 11.9 12.2 12.2 1045 12.0 11.9 12.2 12.1
       50+ 8313 11.9 11.9 12.2 12.2 1395 11.5 11.6 12.0 11.9
    Black men, y
       20-59 434 12.6 12.5 12.9 12.9 1253 12.3 12.4 12.8 12.8
       60+ 135 12.4 12.7 235 11.4 11.9 11.8 12.2
    Black women, y
       20-49 205 11.2 11.2 11.5 11.5 904 10.9 10.8 11.3 11.1
       50+ 255 11.2 11.2 11.5 11.5 442 11.0 10.9 11.3 11.2
    • To convert hemoglobin from grams per deciliter to grams per liter, multiply grams per deciliter by 10.

      — indicates insufficient numbers to determine.

  • Table 4.

    Proposed lower limits of normal for hemoglobin concentration of the blood for white and black adults

    GroupHemoglobin, g/dL
    White men, y
       20-59 13.7
       60+ 13.2
    White women, y
       20-49 12.2
       50+ 12.2
    Black men, y
       20-59 12.9
       60+ 12.7
    Black women, y
       20-49 11.5
       50+ 11.5
    • Based on Scripps-Kaiser data for the 5th percentiles given in Table 2. NHANES data are considered to be confirmatory.

      To convert hemoglobin from grams per deciliter to grams per liter, multiply grams per deciliter by 10.