Prevalence of Iron Deficiency Anemia and Its.3
Prevalence of Iron Deficiency Anemia and Its.3
Prevalence of Iron Deficiency Anemia and Its.3
DOI:
10.4103/joah.joah_44_19 Lamiaa Al-Jamea, Alexander Woodman1, Elmoeiz A. Elnagi, Sultan S. Al-Amri,
Abdulrahman A. Al-Zahrani, Njoud H. Al-shammari, Rawan A. Al-zahrani,
Fatimah S. Al-Yami2, Sultan A. Al- Ameri3
Abstract:
OBJECTIVES: This study’s objectives are to (1) determine the current prevalence of iron‑deficiency
anemia (IDA) and risk factors for female college students at Prince Sultan Military College of Health
Sciences (PSMCHS) in the Eastern Province of Saudi Arabia and (2) address the gap in the current
literature. A written survey in both Arabic and English was administrated to 214 female students,
and only 201 students completed the survey. It was randomly selected from all registered female
students. A number of factors possibly associated with IDA were examined using the Chi‑square test.
CONTEXT: Globally, iron deficiency is known to be the most common nutritional disorder. About
30% of the world’s population are iron deficient (ID). Women seem to be more affected with IDA
than men, which constitute an epidemic public health issue.
AIMS: The aim of the study was to determine the prevalence of IDA and the risk factors among
healthy Saudi undergraduate female college students studying at PSMCHS in Dhahran.
SETTINGS AND DESIGN: A cross‑sectional study on 201 female students (18–25 years) was
Department of Clinical conducted between January and March 2019.
Laboratory Sciences, SUBJECTS AND METHODS: A questionnaire which contains sociodemographic data was completed
Prince Sultan Military, by each participant. Two blood samples were collected from each participant to estimate the iron
College of Health
profile and to analyze the complete blood counts.
Sciences, 1Deanship of
Postgraduate Studies and STATISTICAL ANALYSIS: The statistical analysis was carried out using the Statistical Packages
Research, Prince Sultan for the Social Sciences software.
Military, College of Health
RESULTS: The overall prevalence of IDA was 35.3%. The questionnaire analysis of the dietary habit
Sciences, 2Department of
Medical Laboratory, King and clinical characteristics revealed that family history of hereditary disease and physical activity
Fahad Military Medical have a significant effect on the development of IDA. Statistical analysis showed that having breakfast
Complex-Dhahran, regularly significantly reduced the development of IDA compared with irregularly having breakfast.
Dammam, 3Department CONCLUSIONS: The prevalence of IDA in this study was moderately high, and our results suggest
of Medical Laboratory, that further education regarding IDA is highly encouraged. This is the first study that demonstrated
King Fahad Armed Forces
Hospital-Dhahran, Jeddah,
the prevalence and risk factors of IDA among undergraduate female college students in PSMCHS,
Saudi Arabia and the data generated will provide a database for further studies.
Keywords:
Address for
Eastern Province, iron‑deficiency anemia, prevalence, Prince Sultan Military College of Health
correspondence:
Dr. Lamiaa Al-Jamea,
Sciences, risk factors, Saudi Arabia
Department of
Clinical Laboratory
Sciences, Prince This is an open access journal, and articles are distributed under
Sultan Military College the terms of the Creative Commons Attribution-NonCommercial- How to cite this article: Al-Jamea L, Woodman A,
of Health Sciences, ShareAlike 4.0 License, which allows others to remix, tweak, and Elnagi EA, Al-Amri SS, Al-Zahrani AA, Al-shammari NH,
P. O. Box 33048, build upon the work non-commercially, as long as appropriate et al. Prevalence of Iron-deficiency anemia and its
Dhahran 31448, credit is given and the new creations are licensed under the associated risk factors in female undergraduate
Kingdom of Saudi Arabia. identical terms. students at Prince Sultan Military College of Health
E‑mail: laljamea@psmchs. Sciences. J Appl Hematol 2019;10:126-33.
edu.sa For reprints contact: [email protected]
Table 1 presents the baseline characteristics of the participants are highly educated (45.3%), followed
participants. Age range was from 18 to 25 years, of whom by secondary education (41.8%), and the rest are either
majority was 20–22‑year‑old group (45.3%). First‑year basic or no education. There were 29.4% of them who
level was more (35.8%), followed by 4th year (26.9%), were conscious of anemia, and 20.4% of them had a
3rd year (21.9%), and 2nd year (15 Abundant.4%). 94% family history of hereditary diseases. Considering the
of participants were single (not married), and most of menstrual cycle, the majority of participants (82.1%)
them had a sufficient monthly income. Many parents of reported moderate flow, and relatively few participants
(06.0%) indicated on heavy flow or menorrhagia. Based
Table 1: Baseline characteristics of participants on this method, the diagnosis of menorrhagia is made
(n=201) if the menstrual period lasts for more than 7 days/
Study data n (%) cycle.[7] Moreover, there were 23.4% of the students who
Age group (years) were taking iron supplements where they drink either
<20 50 (24.9) Vitamin C or other mixed supplements. When being
20‑22 91 (45.3) asked about general health status, 10 students reported
>22 60 (29.8) that they were smokers, 29.4% were performing regular
Academic year level physical activities, and 7 students had experienced blood
First year 72 (35.8) transfusion.
Second year 31 (15.4)
Third year 44 (21.9) Figure 1 depicts the regular food consumption of
Fourth year 54 (26.9) participants. The most common food being ascertained
Marital status was chicken (90.0%), followed by fruits (88.6%) and
Single 189 (94.0)
white bread (83.6%), and the least of them was red
Married 12 (06.0)
bread (53.2%).
Educational level of parents
Nothing 4 (02.0)
The most common mental well‑being was delay of
Basic 22 (10.9)
sleep (46.3%), followed by hair loss (38.8%) and lack
Secondary 84 (41.8)
of concentration (32.8%), and the least of them was
University 91 (45.3)
amblyopia (1%) [Figure 2].
Economic situation
Low (<5000) 13 (06.5)
Figure 3 shows the prevalence of IDA. Based on the given
Good (5000‑20,000) 129 (64.2)
Very good (>20,000) 59 (29.3)
criteria, there were 71 (35.3%) identified to be anemic and
Afraid of anemia
130 (64.7%) identified to be normal (nonanemic).
Yes 59 (29.4)
No 142 (70.6)
The dietary habit and clinical characteristics of
Family history of hereditary diseases participants are elaborated in Table 2. Many students are
Yes 41 (20.4) in adherence to regular breakfast (61.2%), and tea and
No 160 (79.6) other mixed drinks were mostly consummated. There
Amount of menstrual cycle were 75.1% of them who have regular tea consumption
Little 24 (11.9) per week where they usually drink it after the meal.
Medium 165 (82.1) Three out of four students have regular coffee drink
Heavy 12 (06.0) per week where it was usually done after or before the
Taking medication meal, whereas more than 60% of them have regular cola
Yes 47 (23.4) intake where they usually drink it during the meal. The
No 154 (76.6)
Type of medication†
Vitamin C 11 (23.4)
Others 36 (76.6)
Smoking
Yes 10 (05.0)
No 191 (95.0)
Physical activity
Yes 59 (29.4)
No 142 (70.6)
Blood transfusion
Yes 7 (03.5)
No 194 (96.5)
†
Only those who are taking medication are included in the analysis Figure 1: Food consumption frequency
Table 3: Univariate analysis for the relationship between iron‑deficiency anemia and baseline characteristics of
participants
Factor IDA (n=71), n (%) Nonanemic (n=130), n (%) UOR (95% CI) P§
Age group (years)
<20 15 (21.1) 35 (26.9) Reference 0.602
20‑22 35 (49.3) 56 (43.1) 1.3 (0.6‑2.8)
>22 21 (29.6) 39 (30.0) 0.9 (0.4‑1.7)
Academic year level (years)
Junior (1st/2nd) 34 (47.9) 69 (53.1) Reference 0.482
Senior (3rd/4th) 37 (52.1) 61 (46.9) 1.2 (0.7‑2.2)
Economic situation
Low (<5000) 3 (04.2) 10 (07.7) Reference 0.630
Good (5000‑20,000) 47 (66.2) 82 (63.1) 1.8 (0.5‑7.4)
Very good (>20,000) 21 (29.6) 38 (29.2) 0.9 (0.5‑1.8)
Afraid of anemia
Yes 25 (35.2) 34 (26.2) Reference 0.178
No 46 (64.8) 96 (73.8) 0.7 (0.3‑1.2)
Family history of hereditary diseases
Yes 22 (31.0) 19 (14.6) Reference 0.006**
No 49 (69.0) 111 (85.4) 0.4 (0.2‑0.8)
Taking medication
Yes 13 (18.3) 34 (26.2) Reference 0.209
No 58 (81.7) 96 (73.8) 1.6 (0.8‑3.2)
Smoking
Yes 2 (02.8) 8 (06.2) Reference 0.298
No 69 (97.2) 122 (93.8) 2.3 (0.5‑10.9)
Physical activity
Yes 28 (39.4) 31 (23.8) Reference 0.020**
No 43 (60.6) 99 (76.2) 0.5 (0.3‑0.9)
§
P value has been calculated using Chi‑square test; **Significant at P≤0.05 level. IDA=Iron‑deficiency anemia; UOR=Unadjusted odds ratio; CI=Confidence interval
When we assessed the relationship between IDA among with IDA. This rate is considered the lowest prevalence
the type of food and the associated health diseases, a of IDA in a particular region of Saudi Arabia (Tabuk,
statistically significant difference was found between Western region). Whereas, according to the study by
frequent consumption of eggs and IDA (P = 0.024) Al Hassan in another city of the same region (Medina,
where participants with IDA are significantly less Western region, Saudi Arabia), the prevalence of anemia
compared to the nonanemic group. With regard to the in female students was relatively high (64%).[12,13] In
associated diseases, stomach ulcer (P = 0.042), indigestion abroad, the incidence of anemia had also been reported
(P = 0.033), and hemicrania (P = 0.044) were all found from different published articles.[6,14‑17]
to have a significant relationship with IDA where those
students with IDA are significantly lower compared to The present study identified 20–22 years’ age group as
the nonanemic group. Other variables included in the test the age group with the highest incidence of IDA (35.3%)
were having no significant relationship to IDA [Table 5]. among college students. This report had also been
ascertained by Al‑Alimi et al., and they reported that
Discussion 64.3% of the males and 54.9% of the females in the age
group of 20–22 years were identified as anemic.[6] This
IDA has been regarded as the underdiagnosed and report has been corroborated by Shill et al., and they
underappreciated women’s health concerns which accounted that 43.4% of students in the same age group
affect women of all ages.[8] In this study, the prevalence were classified as being anemic which was in congruent
of IDA was moderately high (35.3%). In Saudi Arabia, from the findings of our study.[16] However, it is contrary
this finding is consistent from the study published by to the report published in Jordan and China.[14,17] In Jordan,
AlSheikh, Alswailem et al. as well as Almallki et al. where they reported that the prevalence of anemia was higher
articles reported a prevalence of IDA consisting of 38.3%, at the age range of 40–49 years,[14] whereas in China, the
41.6%, and 43.5%, respectively.[9‑11] Arguably, according incidence of anemia was significant at 6–12 months.[17]
to the study by Alzaheb and Al-Amer, conducted in
n=200 female students to estimate the prevalence of IDA IDA occurs when your body does not contain sufficient
and its associated factors, only 12.5% were diagnosed iron to yield Hb. That’s why eating iron supplement
130 Journal of Applied Hematology - Volume 10, Issue 4, October-December 2019
Al‑Jamea, et al.: Prevalence of Iron-Deficiency Anemia and its Associated Risk Factors in Female Undergraduate Students
Table 4: Comparison between Iron‑deficiency anemia among dietary habits and clinical characteristics of participants
Parameters IDA (n=71) Nonanemic (n=130) UOR (95% CI) P§
Dietary habit, n (%)
Are you eating breakfast?a
Regular 36 (50.7) 87 (66.9) Reference 0.024**
Irregular 35 (49.3) 43 (33.1) 0.5 (0.3‑0.9)
Tea intake per weeka
Yes 52 (73.2) 99 (76.2) Reference 0.648
No 19 (26.8) 31 (23.8) 1.2 (0.6‑2.3)
Coffee intake per weeka
Yes 56 (78.9) 102 (78.5) Reference 0.946
No 15 (21.1) 28 (21.5) 0.9 (0.5‑1.9)
Cola intake per weeka
Yes 39 (54.9) 83 (63.8) Reference 0.216
No 32 (45.1) 47 (36.2) 1.4 (0.8‑2.6)
Clinical characteristics, mean±SD
RBC (106/µl)b 4.6±0.4 4.5±0.4 0.5 (0.2‑1.0) 0.053
HBG (g/dl)b 11.4±1.1 12.7±0.8 4.4 (2.8‑6.8) <0.001**
HCT (%)c 36.2±2.6 39.1±2.9 1.4 (1.3‑1.6) <0.001**
MCV (fl)b 79.4±7.9 87.8±5.2 1.2 (1.1‑1.3) <0.001**
MCH (pg)c 25.1±3.3 28.5±2.4 1.6 (1.4‑1.8) <0.001**
MCHC (g/dl)c 31.5±1.8 32.4±2.0 1.4 (1.2‑1.8) 0.003**
RDW (%)c 14.3±2.1 12.3±0.9 0.3 (0.2‑0.5) <0.001**
Ferritin (µg/L)c 8.2±3.9 28.8±24.4 1.3 (1.2‑1.5) <0.001**
Iron (µmol/L)c 7.5±6.1 13.7±7.8 1.3 (1.2‑1.5) <0.001**
TIBC (µmol/L)c 73.0±5.9 60.1±9.6 0.8 (0.7‑0.8) <0.001**
a
P value has been calculated using Chi‑square test; bP value has been calculated using independent t‑test; cP value has been calculated using Mann‑Whitney
U‑test; **Significant at P≤0.05 level. IDA=Iron‑deficiency anemia; UOR=Unadjusted odds ratio; CI=Confidence interval; SD=Standard deviation; RBC=Red blood
cell count; HB=Hemoglobin; HCT=Hematocrit; MCV=Mean corpuscular volume; MCH=Mean corpuscular hemoglobin; MCHC=MCH concentration; RDW=Red cell
distribution width; TIBC=Total iron‑binding capacity
food is necessary to prevent IDA. In this study, the most do not eat breakfast had a risk of anemia by 1.2 times as
common food intakes by the students are chicken, fruits, opposed to those who eat breakfast regularly.[18] In India,
and white bread, whereas the least of them was red Kannan and Ivan mentioned that there was an evidence
bread. Alswailem et al. reported that the most common to suggest that regular breakfast intake will improve the
foods of the female participants were red meat and cognitive function and have positive impact on the health
fish.[11] This has been further validated from the study of children and young adults.[15]
published by Alzaheb and Al‑Amer which indicated
that the university students used to eat meat and fish at Furthermore, we found that physical activity has
least two times per week.[13] Furthermore, both previous a significant relationship with IDA. This finding is
studies reported citrus consumption for at least two times corroborated from the blog posted by Rosen. Based
per week. In nearby country, Al‑Alimi et al. exemplified on her assessment, athletes require more iron than
that vegetables, fruits, red meat, fish, and chicken were the general population as they are more exerting so
the most common foods of the students, with an average much effort which resulted to losing iron in the body.
consumption of 2–3 times per week.[6] High‑intensity training increases iron losses by as
much as 70% as opposed to typical populations. Heavy
Eating regular breakfast is an important activity before sweating causes to lose more iron. RBCs also break down
doing any of the daily routines as breakfast contributes more quickly in those who exercise. The mechanical force
about one‑third of the nutritional needs during the day, of a footstrike during endurance running, for example,
which is quite substantial and that the chance to be anemic can increase the destruction of RBCs in the feet, leading
is relatively small. Students who eat regular breakfast can to a shorter RBC life span.[19]
strengthen attentiveness and make it easier for them to
adapt knowledge. In this article, we further validated Female athletes are even more prone to iron deficiency
that those students who eat regular breakfast are likely as compared to males because of regular menstruation
less to be anemic compared to those students who eat which causes them blood loss. Due to inadequate dietary
irregularly. This finding has been further corroborated intake of iron, athletes may also be at risk for iron
by Andiarna. She reported that breakfast habits have deficiency. Remember, the body is not very effective at
an influence on the incidence of anemia. Teenagers who absorbing dietary iron. Players, specifically menstruating
Journal of Applied Hematology - Volume 10, Issue 4, October-December 2019 131
Al‑Jamea, et al.: Prevalence of Iron-Deficiency Anemia and its Associated Risk Factors in Female Undergraduate Students
Table 5: Relationship between iron‑deficiency anemia linked to IDA, and since this result is substantial, we,
among type of food and associated health diseases therefore, viewed that this finding can shed more light
of participants in the phenomena of the diseases.
Factor Yes (%) P§
IDA Nonanemic When we assessed the independent significant factors
(n=71) (n=130) of IDA, we determined that family history of hereditary
Type of food, n (%)
diseases, physical activity, having breakfast, Hb, HCT,
Red meat 56 (35.9) 100 (64.1) 0.751
MCV, MCH, MCHC, RDW, ferritin, iron, and TIBC were
Chicken 63 (34.8) 118 (65.2) 0.645
all the independent significant factors of IDA. We further
Fish 48 (33.1) 97 (66.9) 0.289
compared the mean of each clinical parameter, and we
Eggs 52 (31.7) 112 (68.3) 0.024**
Fruits 61 (34.3) 117 (65.7) 0.385
are certain that Hb, HCT, MCV, MCH, MCHC, iron, and
Vegetables 58 (34.9) 108 (65.1) 0.804
ferritin were significantly lower than the nonanemic
Legumes 50 (37.0) 85 (63.0) 0.467 group, whereas RDW and TIBC were significantly higher
White bread 60 (35.7) 108 (64.3) 0.794 than the nonanemic group. In Saudi Arabia, the most
Red bread 37 (34.6) 70 (65.4) 0.814 common significant factors of anemia were inadequate
Associated health diseases, n (%) iron, Vitamin C intakes, low consumption of red meat,
Stomach ulcer 4 (16.7) 20 (83.3) 0.042** and family history of IDA,[11,13] whereas in abroad, the
Delay of sleep 32 (34.4) 61 (65.6) 0.801 most common significant factors being ascertained were
Skin decay 6 (54.5) 5 (45.5) 0.170 regular or irregular breakfast, infrequent consumption of
Dizziness 13 (39.4) 20 (60.6) 0.593 vegetables/fruits, meat, fish, chicken, tea drinking, low
Anorexia 8 (47.1) 9 (52.9) 0.290 household income, smoking, bleeding disorder, gender,
Dyspnea 4 (28.6) 10 (71.4) 0.584 Hb, WBC, RBC, platelet, packed cell volume, MCV,
Fatigue 22 (35.5) 40 (64.5) 0.975 MCH, and MCHC.[6,15,16] Interestingly, in China, they
Depression 13 (38.2) 21 (61.8) 0.697 reported that regions, cesarean delivery, premature birth,
Indigestion 3 (14.3) 18 (85.7) 0.033** and neonatal asphyxia were concomitant to anemia.[17]
Hair loss 26 (33.3) 52 (66.7) 0.638
Onychorrhexis 20 (35.7) 36 (64.3) 0.943 We also evaluated the relationship between IDA among
Lack of concentration 22 (33.3) 44 (66.7) 0.680 the type of food and the associated diseases of students
Tension 20 (42.6) 27 (57.4) 0.236
where we found that there is a significant relationship
Tachycardia 7 (33.3) 14 (66.7) 0.840
between frequent eating of eggs and IDA where those
Amblyopia 1 (50.0) 1 (50.0) 0.663
who eat regular eggs are significantly more being
Tinnitus aurium 5 (38.5) 8 (61.5) 0.807
nonanemic. Thus, this finding suggests that frequent
Hemicrania 1 (08.3) 11 (91.7) 0.044**
Disease with bleeding 2 (20.0) 8 (80.0) 0.298
consumption of eggs was effective in preventing IDA.
§
P value has been calculated using Chi‑square test; **Significant at P≤0.05 Considering country comparison, studies in Yemen
level. IDA=Iron‑deficiency anemia reported that rare consumption of vegetables, fruits,
meat, fish, chicken, tea, smoking as well as the low
female endurance competitors, need to be carefully family income are essential factors leading to IDA[6].
mindful of iron intake in order to meet their bodies’ While the studies from Bangladesh confirmed the fact
demands. Those following a strict vegetarian or vegan that the consumption of vegetables, fruits, meat, fish,
diet can be at even higher risk for iron deficiency due to chicken are positive indicators of iron-deficient non-
the decreased absorption of nonheme iron found in plants anemic.[16] On the other hand, diseases such as stomach
and fortified foods.[19] Alaunyte et al. further noted that ulcer, indigestion, and hemicrania are detected to
the majority of research studies support the hypothesis have significant association with IDA where students
of the beneficial effect of dietary iron interventions on being nonanemic are significantly more compared to
the balance of iron in iron‑depleted female athletes. students with anemia.Alswailem et al. suggested that
However, the direct impact on exercise performance menstruation cycle disorder, bleeding disorder, and
among female athletes is unclear. Nevertheless, there possible experience of blood transfusion, the experience
seems to be evidence that dietary iron interventions of IDA, and the genetic history of IDA might directly
may assist in maintaining iron status in female athletes, correlate to anemia. Additionally, Kannan and Ivan
especially during intensive training and competition reported that bleeding disorder was significantly
regimens.[20] associated with anemia.[11,15]