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Your iron is normal — why are you still exhausted?

Low iron isn’t always behind pale skin, shortness of breath, and fatigue. Here’s what could be happening.

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August 9, 2026 4:00pm EDT

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FROM DR. BERZIN:

My iron is fine, so why does my doctor think I might be anemic?

Most people learn to associate anemia with low iron, and stop there. But a high MCV in your bloodwork can point to a completely different root issue, tied to B12 or folate levels.

— Robin Berzin, MD, Founder & CEO, Parsley Health

Condition Spotlight: Macrocytic Anemia

Two types of Macrocytic Anemia: Megaloblastic Anemia, Nonmegaloblastic Anemia

Macrocytic anemia happens when red blood cells grow larger than normal, making them less efficient at carrying oxygen throughout the body. If you have this condition, you might experience anemia symptoms even when your iron and ferritin levels are completely normal.

Megaloblastic anemia is the more common type of macrocytic anemia that stems from a B12 or folate deficiency. Non-megaloblastic anemia can be caused by alcohol use, liver disease, hypothyroidism, certain medications, or bone marrow disorders.

Go beyond an iron check. Parsley Complete Care digs into the root cause behind fatigue, pale skin, and shortness of breath and pairs you with a clinical team that gets results.

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These groups are at highest risk for macrocytic anemia

Your risk is mostly tied to how well your body can get, absorb, and use B12 and folate. Some groups are more likely to develop the condition:

People eating plant-forward or vegan diets. B12 comes almost exclusively from animal products. Get levels back up with fortified foods and/or a high-quality supplement.
Anyone with a chronic digestive condition. Celiac disease, Crohn's, SIBO, and other conditions that damage the small intestine can impair B12 and folate absorption.
People on certain medications. Acid reducers like Prilosec, methotrexate, metformin, some antiseizure drugs, and select cancer treatments and antibiotics can interfere with red blood cell formation.
Regular or heavy alcohol users. Alcohol can impair folate absorption and storage, and is also linked to liver disease — another independent driver of macrocytic anemia.
Pregnant women. Pregnancy sharply increases folate needs.
Adults over 60. With increased prevalence of B12 deficiency, primary bone marrow disorders, and thyroid problems comes an increased risk for macrocytic anemia.

If you’re in one or more of these categories and experiencing symptoms, it’s worth an MCV, B12, and folate check — even if your iron panel looks normal.

Read More: Macrocytic Anemia vs Megaloblastic Anemia

BIOMARKER SPOTLIGHT

MCV and Hemoglobin

Low hemoglobin confirms that anemia is present. An elevated MCV (Mean Corpuscular Volume) tells us why: your red blood cells are abnormally large, pointing towards B12 or folate deficiency disrupting normal cell development.

It’s useful to test both at once, because MCV can rise before hemoglobin drops — meaning it can flag an emerging issue before full-blown anemia has set in. It can also explain anemia symptoms that persist despite a normal iron panel.

Get a clear answer on what’s behind your symptoms. Parsley’s Clinical Lab Review looks beyond a standard iron panel to test MCV and hemoglobin together.

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What We're Taking (and Why):

Daily Dose Multivitamin

If your B12 or folate levels could use support, your multivitamin's form matters as much as its dose. Daily Dose Multivitamin is formulated with methylated B vitamins — 5-MTHF folate and methyl B12 — bioactive forms designed for better absorption than the synthetic versions found in most basic multivitamins.

In addition to B vitamins, Daily Dose delivers 20+ essential nutrients and 13 plant-based phytonutrients to help fill common dietary gaps.

Get Daily Dose Multivitamin

“The best daily multi I have found! No weird aftertaste and truly works.” - Jennifer S.

What members are saying:

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“What sets Parsley apart is their functional health model — they actually get to the root of what's going on rather than just managing symptoms. I'm so grateful for this team and can't recommend them enough.”

- Lisa G., Parsley Health Member

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With anemia, symptoms like dizziness, shortness of breath, pale skin, and cold extremities overlap, making it hard to know where to start. The PSI takes only a few minutes to complete, and looks across body systems to help you understand what your symptoms might be telling you.

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