In the GBD 2019, anemia is defined as a reduction in the concentration of hemoglobin in the blood, irrespective of the underlying cause or the morphology or function of erythrocytes (15). In the GBD framework, anemia is classified as an impairment—a physical state with multiple causes, such as DID, diabetes and kidney diseases, digestive diseases, maternal hemorrhage, and others (15).

Total anemia is estimated based on the modeled mean and standard deviation of hemoglobin concentration as inputs. Individual-level data sources are incorporated to produce an estimated hemoglobin distribution for each age-sex-location-year combination. Hemoglobin thresholds for anemia are based on the WHO standards and vary by sex, age, and pregnancy status (15, 19).

To attribute the estimated total anemia to different anemia-causing conditions, the GBD modelers estimate counterfactual hemoglobin distributions (i.e., hypothetical distributions of hemoglobin if no conditions caused anemia) based on (i) the age- and sex-specific prevalence of each anemia-causing condition and (ii) the condition’s quantitative effect on hemoglobin concentration, known as the “hemoglobin shift” for that condition (15). The total hemoglobin shift in a population is the difference between the predicted hemoglobin concentration and the “normal” hemoglobin concentration for each age-sex-location-year combination. “Normal” hemoglobin is defined as the 95th percentile of the global distribution of mean hemoglobin levels within each age group, sex, and year (14). Cause-specific hemoglobin shifts are derived by meta-analysis of published studies (cohort studies, case control studies, or treatment trials) that compare hemoglobin concentrations among populations with and without the condition and are described in detail elsewhere (14). Anemia severity levels (mild, moderate, and severe) are assigned to each cause based on the difference between the counterfactual and observed hemoglobin distributions in each population group, forcing the sum of the difference between the counterfactual and observed prevalence of anemia across causes to equal the total anemia of each severity level.

Point estimates and 95% UIs generated by the GBD 2019 modelers are reported. The uncertainty ranges in the estimated DALYs incorporate the uncertainty in the prevalence and the uncertainty resulting from the modeling process to generate the disability weight (15). A global standard reference population, developed by demographers at the Institute for Health Metrics and Evaluation, is used to derive an age-standardized rate to provide a weighted average of age-specific rates for each population. This allows comparisons over time, independent of the age structure of each population.

DALYs from the GBD 2019 dataset were analyzed by age, sex, geography, and cause to assess anemia’s health impact in the US. This study focused on dietary iron deficiency (DID), diabetes, kidney disease, digestive disease, and maternal and gynecological conditions.

The funder had no role in the primary data collection or study design of the GBD study. However, the funder was involved in the study design, data analysis, and provided support for the medical writing of the secondary analysis described here.

In 2019, an estimated 218,855 (95% UI, 257,649–657,344) DALYs were lost to anemia in the US, with over half attributed to dietary iron deficiency (DID) (228,240 [140,291–360,026]). DID accounted for the largest share of DALYs in both male and female individuals (Table 1), with 61,499 DALYs among male individuals and 166,741 among female individuals—nearly three times more.

Over half of the overall anemia-related DALYs were experienced by those in the 10–54 age group (51.8%; 217,105 [127,751–343,586]; Table 1). Similar to the overall trend, a large share of the anemia-related DALYs were due to DID (127,368 [73,706–203,772]; Table 1), with female individuals in this age group experiencing higher rates of DALYs than male individuals (Table 1).

Two major cause categories—diabetes and kidney diseases and digestive diseases—together contributed a significant portion of anemia-related DALYs (65,888 and 12,195, respectively), making them the second-largest causes of the anemia burden. A smaller proportion of anemia-related DALYs among female individuals was due to maternal hemorrhage (3,660 [2,024–6,121]) and gynecological diseases (10,568 [5,908–18,043]) (Table 1). As expected, this burden was largely experienced by female individuals in the 10–54 age group, who accounted for all of the burden of maternal hemorrhage (100%; 3,660 [2,024–6,121]) and most of the burden of gynecological diseases (96.2%; 10,166 [5,605–17,313]; Table 1). Anemia-related DALYs caused by gynecological diseases in this age group were divided into two categories: DALYs due to uterine fibroids (1,118 [666–1,779]) and those due to other gynecological diseases (9,048 [4,749–15,740]).

Female individuals accounted for 74.2% (310,673) of the total anemia-related DALYs, with 188,741 of these in female individuals aged 10–54 years. Across all age groups, female individuals experienced higher anemia-related DALY rates than male individuals (Table 1; Supplementary Table 2).

Among female individuals in each age group, DID was the foremost cause of anemia-related DALYs (Supplementary Table 1). Among female individuals aged 0–9 years and 10–54 years, hemoglobinopathies and hemolytic anemias were the second leading cause of anemia-related DALYs. In contrast, among female individuals aged ≥55 years, diabetes and kidney diseases were the second leading cause of anemia-related DALYs (Supplementary Table 1). Although male and female individuals aged ≥55 years experienced generally high rates of anemia-related DALYs due to DID, digestive diseases, and diabetes and kidney diseases, DALY rates per 100,000 female individuals were comparatively higher than those for 100,000 male individuals for each cause (Supplementary Table 2).

An in-depth exploration of the DALY rates among different age groups revealed starkly different trends between male and female individuals. Female individuals aged 35–44 years experienced the highest anemia-related DALY rates due to DID and digestive diseases, whereas the corresponding rates for male individuals increased steadily with age. However, male individuals had higher DALY rates than female individuals in the ≥80-year age group for DID and in the ≥90-year age group for digestive diseases (Figures 1A,B). DALY rates for anemia due to diabetes and kidney diseases were generally higher among female individuals than male individuals in age groups <80 years and increased somewhat steadily with age rather than spiking in female individuals in their 30s and 40s, as seen in DID and digestive diseases (Figure 1C).

The burden of severe anemia followed a trend similar to that of overall anemia. The DALY rate among female individuals of all ages was three times that of male individuals of all ages (Table 2). Among those aged 10–54 years, female individuals had a DALY rate approximately 17 times higher than that of male individuals for severe anemia (Table 2). Similarly, female individuals of all ages had a DALY rate for severe anemia due to DID approximately three times that of male individuals, and female individuals aged 10–54 years had a DALY rate for severe anemia due to DID approximately 10 times that of male individuals (Table 2). Diabetes and kidney disease were also major causes of severe anemia in both sexes (Table 2).

From 1990 to 2019, total health loss due to anemia in the US rose from 332,449 (204,344–510,889) to 418,855 (257,649–657,344), representing an increase of 26% over three decades. In female individuals, this increase was most prominent since 2001 (Figure 2A). Female individuals experienced 212,930 (133,559–326,136) anemia-related DALYs in 2001, which then rose by 46% to 310,673 (190,806–483,052) in 2019. Among female individuals aged ≥55 years, there was an even sharper increase, more than doubling from 48,775 (30,687–75,803) in 2001 to 101,293 (57,831–164,094) in 2019 (Figure 2B).

The DALY rates per 100,000 female individuals indicate that some of this increase in health loss may be due to demographic changes, such as an increase in the number of female individuals in the ≥55 years group. In 2019, female individuals experienced lower DALY rates than in 1990, although rates have been increasing since the early 2000s. The lowest estimated DALY rate among female individuals in the US occurred in 2003, at 146 (94–224) DALYs per 100,000 female individuals (Figure 2C). Although DALY rates among male individuals were far lower than those in female individuals, their trend was similar, decreasing from 58 (34–95) in 1990 until the early 2000s, then increasing to reach 67 (38–112) in 2019.

DALY rates in 1990 were different between female individuals aged 10–54 years and those aged ≥55 years. However, DALY rates have since risen from their respective low points in the 2000s for each group and increased in 2019 to 196 (112–317) for female individuals aged 10–54 years and 197 (114–315) for female individuals aged ≥55 years (Figure 2D).

The rates of health loss due to anemia, both overall rates and those attributed to different causes, varied among US states even after adjusting for different population sizes and age structures (Supplementary Table 3; Figures 3A–E). Age-standardized DALYs per 100,000 population in the US in 2019 ranged from 175 (102–282) in Mississippi to 91 (50–158) in Minnesota (Supplementary Table 4). Among female individuals, these rates ranged from 256 (142–423) in Mississippi to 133 (71–228) in Minnesota. Comparing 1990 and 2019, although the order of states with the highest rates of anemia-related DALYs per 100,000 changed, the states in the top 10 largely remained the same (Supplementary Table 3). Between 1990 and 2019, 16 states experienced an increase in DALY rates (Supplementary Table 4). Among the states with the top ten DALY rates in 1990, the District of Columbia, Louisiana, South Carolina, Georgia, and Maryland had lower DALY rates by 2019 (Supplementary Tables 3, 4).

DALY rates due to different causes varied widely among states. Mississippi recorded the highest rate of anemia due to DID (Figure 3A); New York and West Virginia had the highest rates of anemia due to digestive diseases (Figure 3B); South Dakota, Kansas, and Pennsylvania had the highest rates of anemia due to gynecological diseases (Figure 3C); Kansas had the highest rate of anemia due to maternal hemorrhage (Figure 3D); and Mississippi had the highest rate of anemia due to diabetes and kidney diseases (Figure 3E).

We searched Ovid MEDLINE^® from 1946 to 10 January 2025 using the search terms (anemia) AND ([DALY] OR [disability-adjusted life year] OR [Global Burden of Disease]) AND (United States), with no language restrictions. This search did not yield any references. However, when the term “United States” was excluded from the search string, 24 references were retrieved. Of these references, 14 were discarded as irrelevant because they pertained to anemia in the context of parasitic infections, involved studies based on the Global Burden of Disease Study (GBD) data that were not related to anemia, or examined the cost-effectiveness of health interventions. Three studies have described the global burden of anemia based on the GBD data, along with a commentary on one of these articles and a study focused on anemia in female individuals of reproductive age in low- and middle-income countries. To the best of our knowledge, this is the first study to examine the burden of anemia in the US, segmenting the data by various demographic factors.

In this analysis, the GBD 2019 dataset was used to examine the burden of anemia in the US from 1990 to 2019 by sex, cause, age, and geographic area. To the best of our knowledge, this is the first subnational assessment of anemia in the US that examines disability-adjusted life years (DALYs) across different demographics and geographies. This study is also the first to describe the burden of anemia by age, sex, and cause, to explore geographic variation in anemia-related DALYs by cause; and to analyze historical trends of anemia-related DALYs by geography.

This analysis of the GBD 2019 data showed an increase in the burden of anemia over time. This burden was concentrated in specific groups of people (female individuals and the older adults), with some locations (Mississippi, the District of Columbia, and Alabama) experiencing a greater burden than others. These findings highlight the importance of continued efforts toward the screening, diagnosis, and management of anemia. The World Health Organization has declared anemia a global health priority, with anemia testing included in the essential list of in vitro diagnostics. The comprehensive nature of our study provides policy-relevant information to guide public health programs in addressing anemia care for specific populations in the US.