To,
The Editor
Sub: Submission of Manuscript for publication
Dear Sir,
We wish to submit a manuscript entitled “prevalence of anemia and its associated
factors among school children in south district of Makkah, Saudi Arabia” for
consideration by the Saudi medical journal as an original research article. We confirm
that this work is original and has not been published elsewhere nor is it currently
under consideration for publication elsewhere.
Please address all correspondence concerning this manuscript to Roaa Omar Altalhi at
[email protected]
Thank you for your consideration of this manuscript.
Sincerely
Prevalence of Anemia and its Associated Factors among School Children in
South District of Makkah, Saudi Arabia
Roaa Omar Altalhi 1*, Zuriati bt Ibrahim2*, Norhasmah Sulaiman 3*, Fahaid Alhashem 3**
1
M.Com.Nut, 2 Lecturer, 3 Associate Professor
*
Department of Nutrition and Dietics, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
** Department of Physiology College of Medicine
King Khalid University
‫ المملكة العربية‬،‫انتشار فقر الدم والعوامل المرتبطة بها بين أطفال المدارس في منطقة جنوب مكة المكرمة‬
‫السعودية‬
.*3‫ فهيد ال هاشم‬.‫د‬,*3‫ نور هسما سليمان‬.‫ د‬،*2‫ زرياتي ابراهيم‬.‫* د‬1‫رؤى عمر الطلحي‬
‫استاذ مشارك‬3,‫ محاضر‬2 ,‫طالب ماجستير‬1
‫ كلية الطب والعلوم الصحية‬،‫* قسم التغذية وعلم التغذية‬
‫جامعة بوترا ماليزيا‬
‫ كلية الطب‬،‫** قسم علم وظائف األعضاء‬
‫جامعة الملك خالد المملكة العربية السعودية‬
Corresponding author: Roaa Omar Altalhi , [email protected]
Abstract
Anemia remains a major nutritional health problem worldwide. Children are the
vulnerable group at great risk of anemia. The objective of this study was to determine
the prevalence and predictors of anemia among school children (aged 7 to 9 years) in
Makkah, Saudi Arabia. A cross sectional study design was carried out between
October 2013 and December 2013. A total of 240 children were selected using
multistage sampling method from 15 primary schools in south district of Makah. A
questionnaire was used for data collection. The dietary intakes data were analysed
using Nutritionist Pro software. The Hemoglobin level (Hb) was measured by
automated hematology counters method. Descriptive and multivariate analyses were
conducted to determine the prevalence and associated factors of anemia. The overall
prevalence of anemia was found to be 18.0% (20.8% among girls and 15.0% among
boys). Significant associations were found between anemia and total energy, vitamin
B12 and folic acid (p < 0.05). In particular, vitamin B12 (AOR= 0.45) and folic acid
were significant predictors of anemia. In conclusion, results provided the baseline
information on anemia and its predictors among school children in Makah. Thus,
especial attention should be given to intervention programs on healthy dietary intake
in order to decrease the prevalence of anaemia.
‫ملخص الدراسة‬
‫يعتبر فقر الدم بين األطفال مشكلة صحية عامة معتدلة في المملكة العربية السعودية وبين أهم مشاكل الصحة‬
‫العامة في جميع أنحاء العالم‪ .‬يعتبر فقر الدم مشكلة صحيه غذائية رئيسية في جميع أنحاء العالم‪ .‬األطفال هم الفئة‬
‫األكثر عرضه لخطر اإلصابه بفقر الدم‪ .‬هذه دراسة مقطعية تهدف إلى تحديد مدى انتشار فقر الدم والمتنبئات‬
‫الخاصه به بين أطفال المدارس (العمر بين ‪ 9-7‬سنوات) في مكة المكرمة‪ ,‬المملكه العربيه السعوديه‪ .‬هذه‬
‫الدراسه مقطعيه بين اكتوبر الى ديسمبر ‪ .2013‬وقد تم اختيار ‪ 240‬طفال باستخدام أسلوب العينة متعددة المراحل‬
‫من ‪ 15‬م درسة ابتدائية في منطقة الجنوب من مكة‪ .‬تم استخدام االستبيان لجمع البيانات‪ .‬وقد تم تحليل البيانات‬
‫المتحصالت الغذائية باستخدام برنامج التغذية برو‪ .‬وقد تم قياس مستوى الهيموجلوبين (خضاب الدم) من خالل‬
‫اآللية طريقة عدادات الدم‪ .‬أجريت تحليالت وصفية ومتعددة المتغيرات لتحديد مدى انتشار فقر الدم والعوامل‬
‫المرتبطة به‪ .‬وبلغت نسبة انتشار فقر الدم بين المشاركين ‪ ٪18‬مع انتشار أعلى بين الفتيات (‪ )٪20.8‬بالمقارنة‬
‫مع الذكور (‪ .)٪15.0‬وجدت الدراسه عالقه إحصائية بين فقر الدم والطاقة ‪ ،‬وفيتامين ‪ B12‬وحامض الفوليك ‪(p‬‬
‫‪ .< 0.05).‬على وجه الخصوص‪ ،‬فيتامين ‪ (AOR= 0.45) B12‬وحمض الفوليك هي متنبئات فقر الدم بين‬
‫اطفال المدارس في مكه‪ .‬وفي الختام‪ ،‬قدمت نتائج المعلومات األساسية عن فقر الدم و المتنبئات الخاصه به بين‬
‫أطفال المدارس في مكة المكرمة‪ .‬وبالتالي‪ ،‬ينبغي إيالء اهتمام خاص لبرامج التدخل على المدخول الغذائي‬
‫الصحي من أجل تقليل انتشار فقر الدم‪.‬‬
INTRODUCTION
Anemia is one of the most critical public health problems affecting children
worldwide.[1] It occurs when the number of the red blood cells is not enough to meet
the body physiological requirements, and this happens when the level of hemoglobin
is less than 11.0 g/dl.[2] Anemia is associated with serious effects among school
children including growth retardation; impair academic performance, poor health
conditions and nutritional status. [3] [4] Global estimate suggest that 305 million
school going children are anemic.[1]
The prevalence of anemia in Saudi Arabia varies among different regions. A
recent study conducted among 1117 children (aged 5 to 12 years) in the central region
of Saudi Arabia (Riyadh) showed that 22.2% of children were anemic.[5] Previous
study from the western region of Saudi Arabia ( Jeddah) reported a higher prevalence
of anemia (35.8%) among elementary school student.[4] However, this study was
focused on iron deficiency anemia and was limited to female school children.
Measurement of Hemoglobin concentration is the primary test for diagnosis of
anemia. Data on anemia and its nutritional status and dietary intake predictors among
school children in Saudi Arabia is lacking. Hence, this study was carried out to
determine the prevalence and predictors of anemia among school children in south
district of Makkah, Saudi Arabia.
Materials and Methods
Study design, Setting and Sample: This was a cross sectional school based study
conducted in south Makah from October 2013 and December 2013. Makkah is a city
in the Hejaz and is the capital of Makkah province in Saudi Arabia. Makkah AlMukarramah is the holy capital located in the western region of the Kingdom of Saudi
Arabia. In the south district, there are 74 primary schools (38 boys’ schools and 36
girls’ schools). This study targeted primary school students between the ages of 7 and
9 years in south district of Makkah. The sample size for this study was determined
according to [6] for any hypothesis testing study which requires multivariate
statistical analysis. The sample was increased by 10% to compensate for no response,
so the final sample size was 240 students. The schools were selected using multi stage
cluster sampling. A total of 15 elementary schools with six girls’ and nine boys’
schools were randomly selected in this study. The Principal from each selected
schools were contacted to obtain permission to conduct the study. All the students
from grade 1, 2 and 3 from each selected school were recruited to participate in this
study. They were explained about the research and given parental consent form and
information sheet. Those who returned the consent form with parents’ permission
were eligible to participate in the study.
Data Collection/Study Instrument
The children's socio-demographic characteristics (age, gender, number of children per
household, parents educational level and family’s monthly income), and their dietary
intake data were collected via a questionnaire (Arabic language) filled out by parents
or guardians. The information on the dietary intake was collected using 2-day food
record sheets. The Hemoglobin level (Hb) was measured by automated hematology
counters method. A 5-ml of venipuncture blood was drawn by a trained nurse. The
blood samples were then transferred from schools to clinical laboratory (haematology
lab) at Modern Medical Clinics in south Makkah for analysis. Lastly, the
determination of anemia in the respondents by hemoglobin levels was done using the
anemia classification by WHO (Hb <11.5 g/l)[2].
Ethical clearance: Prior to data collection, ethics approval to conduct the study was
obtained from the Medical Research Ethics Committee Faculty of Medicine and
Health Sciences, Universiti Putra Malaysia (UPM). Approval was also obtained from
the Education department in Makkah and school health department, Ministry of
Health. Written consent was obtained from the parents of all participants before data
collection
.
Data analysis: The Hemoglobin level (Hb) was measured by automated hematology
counters method. The dietary intake of the respondents from the food record was
analysed using nutritionist-Pro software. All the obtained data was analysed using
SPSS version 21. Descriptive statistics were conducted for the variables and presented
as frequencies, percentages and mean. T-test for was used to determine significance
association before analyzing the data (only the factors with P < 0.05 were used to
develop the regression model). Binary logistic regression (with the method of
Backwards Wald) was used to obtain odds ratios (ORs) and 95% confidence intervals
(95% CIs) to determine the predictors of anemia. Non-significant factors were
removed from the final model. A p-value less than 0.05 is considered statistically
significant.
Results
A total of 240 school children (120 girls and 120 boys) aged 7–9 years from fifteen
primary schools were included in the study. Table 1 presents the socio demographic
characteristics of the respondents. The mean ± SD age was 7.90 ± 0.80 years ranged
between 7 and 9 years. Vast majority of the respondents (87.9%) had 2-4 siblings. In
addition, majority of them (88.3%) were from household size between four to six
people. The results also showed that, more than half of the respondents fathers
(52.1%) and mothers (55.0%) had education at tertiary level. More than half of the
respondents (54.2 %) had monthly household income of more than the average
monthly income of Saudi Arabia (> 13106 SAR = 3494.77 USD) [7].
Table 1. Socio-demographic characteristics of the respondents (n=240)
Boys n=120
Girls n=120
Total n=240
n (%)
n (%)
n (%)
Socio-demographic
Mean ± SD
Age (years)
7
28 (23.3)
51 (42.5)
79 (32.9)
8
39 (32.5)
48 (40.0)
87 (36.3)
7.98±0.80
9
53 (44.2)
21 (17.5)
74 (30.8)
Number of siblings
1
4 (3.3)
2 (1.7)
6 (2.5)
2-4
104 (86.7)
107 (89.2)
211 (87.9)
3±1.017
>4
12 (10.0)
11 (9.2)
23 (9.6)
Mother's
educational level
Primary
4 (3.3)
6 (5.0)
10 (4.2)
Secondary
48 (40.0)
50 (41.7)
98 (40.8)
Tertiary
68 (56.7)
64 (53.3)
132 (55.0)
Father's
educational level
Primary
Secondary
62 (51.7)
53 (44.2)
115 (47.9)
Tertiary
58 (48.3)
67 (55.8)
125 (52.1)
Household income
≤13106 SAR
57 (47.5)
53 (44.2)
110 (45.8)
>13106 SAR
63 (52.5)
67 (55.8)
130 (54.2)
Household size
<4
4 (3.3)
1 (0.8)
5 (2.1)
4-6
104 (86.7)
108 (90.0)
212 (88.3)
5 ±1.027
>6
12 (10.0)
11 (9.2)
23 (9.6)
Note: (n) indicate for total respondents, Primary (non-formal and elementary),
Secondary (intermediate and high), Tertiary (college and post collage). 1US dollar
=3.75 SAR
Prevalence of anemia
Anemic classified based on cutoff value of hemoglobin level (<115g/L) for children
age ranged from 5 to11 years (WHO, 2011). Overall, the prevalence of anemia in this
study was (18%). The prevalence of anemia found to be higher among girls' (20.8%)
compared to boys' (15%).
Factors Associated with Anemia
An independent samples t-test was conducted to determine the difference in mean
dietary intake between anemic and non-anemic. Table 2. shows significant difference
in mean dietary intake of vitamin B12 and folic acid between anemic and non-anemic
children (p < 0.05). Nonetheless, no significant difference was found in mean dietary
intake of vitamin B6, calcium, Iron and total energy of between the two groups (p >
0.05). The mean of vitamin B12 intake was higher among non-anemic children
(2.16±0.71 mg) compared to those anemic children (1.79± 0.68 mg). The results also
show that, the mean of folic acid intake among the non-anemic children (285.67±71.0
mg) was higher than that among the animic group (249.19±74.38 mg).
Table 2. Independent t-test between anemic stats with dietary intake of the
respondents (n=240)
Variable
Anemic
n=43
Mean ± SD
non-anemic
n=197
Mean ± SD
t
P-value
Total
energy(kcal)
1280± 171.24
1197± 205.96**
3.410
.001
Vitamin B6( mg)
0.84± 0.27
0.87± 0.22
.690
.491
Vitamin B12
(mg)
1.79± 0.68
2.16±0.71*
3.033
.003
Folic acid (mg)
249.19±74.38
285.67±71.0*
3.026
.003
Calcium (mg)
548.05 ± 128.71
576.32± 153.24
1.126
.261
Iron (mg)
9.25± 2.33
9.93±2.35
1.733
.084
Note: * p<0.05, **p<0.001 Significant difference between anemic status (Independent
sample t-test), (n) indicate for total respondents
Logistic Regression Analysis
A multivariate analysis was conducted to determine the predictors of anemia. Two
variables were selected to be entered into the model this include VB12 and folic acid.
Table 4 shows the results of the multivariable logistic regression analysis. The model
with the two included factors demonstrated significant logistic regression model test
(P< .001). The results showed that both factors (vitamin B12 and folic acid) were
significant predictors of anemia. Anemic children showed significantly lower level of
B12 (OR=0.45; 95% CI: 0.26-0.78) and folic acid (OR=0.99; 95% CI: 0.98-0.99)
compared to non- anemic children.
Table 3. Multiple Logistic regression model of anemia
B
(SE)
Wald
p
Odds
Ratio
(95%) CL
Vitamin B12
-.801-
.281
8.139*
.004
.45
0.26-0.78
Folic acid
-.008-
.003
7.515*
.006
.99
0.98-0.99
variable
Note: Significant*p<0.001
Discussion
The criterion for defining of anemia in this study was based on based on hemoglobin
cutoff values for children, as determined by the World Health Organization (WHO)
]1[. Accordingly, the magnitude of anemia determined in this study (18.0%) is
considered as a mild public health problem (prevalence of anemia 5.0 to 19.9)
according to World WHO standards. There was no case of severe anemia (prevalence
of anemia ≥40 )found among the children in this study.
The finding of this study is in agreement with those of related studies conducted
in different parts of Saudi Arabia. According to theses study the prevalence of anemia
among the children ranges from 15.5% to 22.3%. [5, 8-10]
The prevalence of anemia found in this study is higher as compared to the
finding (12.2 %) in a study conducted in Kenitra Morocco conducted among school
children aged [11]. However, it is still significantly lower than those rates reported by
other Asian and African countries such as India (52.8%), Yemen (48.7%), china
(24.9%) and Sudan (29.7%). [12 ,13-14]
The prevalence of anemia from different regions of Saudi Arabia was observed to be
varied and this could be attributed to various reasons ranging from regional dietary
habits, and cultural and geographical factors.
The observed differences in the findings between countries may be attributed to the
difference in ethnicity, geographical location, socio-demographic profiles of the
children, accessibility to nutritious food, health care and sanitation system to
socioeconomic status.
In the present study, vitamin B12 and folic acid were found to be significant
predictors of anemia. In the same study conducted by Villalpando et al., (2003) it was
found that there was no association between hemoglobin concentrations with folate
and vitamin B12. Similarly, in Colombia both folate and vitamin B12 were found to
have no significant relation with hemoglobin concentration in a survey conducted
among children age 5 to12 years by [15].
Moreover, there was no differences in folate between anemic and non-anemic [16].
However, the hemoglobin level in a study by Pasricha et al. ,(2010) conducted in rural
India among children aged 12 to 23 months showed a positive relation between folic
acid and vitamin A intake [17].
These findings could be explained by the important role of vitamin B12 and folic acid
in anemia. Therefore, the result is this study can be said to be consistent with that
reported [18], where micronutrient deficiencies, folate and vitamin B12 are found to
play a role in the development of anemia.
Limitations of the study
1. The first limitation of this study was the cross-sectional study design.
2. In this study only children in primary schools among 7 to 9 years of age in
south Makkah are involved thus; the study findings cannot be used as a
representative of Saudi Arabia or all children in Makkah.
3. The data was collected using self-administered questionnaire which relied
upon the honesty and certainty of the respondents.
In conclusion, the prevalence of anemia among school children in this study is lower
than that stated for the national and international level. Vitamin B12 and folic acid are
significant predictors of anemia. Screening for B12 deficiency anemia among children
should be regulated to high-risk groups. Appropriate education programs ought to be
also considered in order to improve families and students’ awareness on healthy
dietary habits.
Acknowledgments
I would like to thank the Ministry of Health in Saudi Arabia and school health unit in
Makkah and Ministry of Education in Saudi Arabia. Furthermore, special thanks to all
nurses who help me to collect the blood sample and also for the staffs of schools in
Makkah who help me to collect the data on time. Last but not least,we gratefully
acknowledge the children and their parents for their participation in this study.
References
1.
2.
3.
4.
McLean, E., et al., Worldwide prevalence of anaemia, WHO vitamin and
mineral nutrition information system, 1993-2005. Public Health Nutrition,
2009. 12(04): p. 444-454.
WHO, Haemoglobin concentrations for the diagnosis of anaemia and
assessment of severity. Vitamin and Mineral Nutrition Information System, in
World Health Organization. Geneva, Switzerland: World Health
Organization. 2011.
Kemmer, T.M., et al., Anaemia, its correlation with overweight and growth
patterns in children aged 5-10 years living in American Samoa. Public Health
Nutrition, 2009. 12(05): p. 660-666.
Gari, M.A., Prevalence of Iron Deficiency Anemia among Female Elementary
School Children in Northern Jeddah, Saudi Arabia. Journal of King Abdulaziz
University-Medical Sciences, 2008. 15(1): p. 63-75.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Gad, A., et al., Anemia among Primary School Children (5 -12 years) in
Riyadh Region, Saudi Arabia: A Community-Based Study. Canadian Journal of
Clinical Nutrition, 2013. 1(1): p. 27-34.
Aday, L.A. and L.J. Cornelius, Designing and conducting health surveys: a
comprehensive guide. 2011: John Wiley & Sons.
CDSI. Household expenditure and income survey bulletin1434 H. Central
Department of Statistics and Information (CDSI), Saudi Arabia 2013 [cited
2013 12-6]; Available from: http://www.cdsi.gov.sa/english.
Abalkhail, B. and S. Shawky, Prevalence of daily breakfast intake, iron
deficiency anaemia and awareness of being anaemic among Saudi school
students. International journal of food sciences and nutrition, 2002. 53(6): p.
519-528.
El-Hazmi, M.A.F. and A.S. Warsy, The pattern for common anaemia among
Saudi children. Journal of Tropical Pediatrics, 1999. 45(4): p. 221-225.
Abou-Zeid, A.H., et al., Anemia and nutritional status of schoolchildren living
at Saudi high altitude area. Saudi medical journal, 2006. 27(6): p. 862-869.
El Hioui, M., et al., Risk factors of anaemia among rural school children in
Kenitra, Morocco. 2008.
Al-Zabedi, E.M., et al., Prevalence and risk factors of iron deficiency anemia
among children in Yemen. American Journal of Health Research, 2014. 2(5):
p. 319-326.
Gao, W., et al., Severity of anemia among children under 36 months old in
Rural Western China. PloS one, 2013. 8(4): p. e62883.
Mohamed, S. and M.D. Hussein, Prevalence of Thinness, Stunting and Anemia
Among Rural School-aged Sudanese Children: A Cross-sectional Study.
Journal of tropical pediatrics, 2015: p. fmv028.
Arsenault, J.E., et al., Provision of a school snack is associated with vitamin
B-12 status, linear growth, and morbidity in children from Bogota, Colombia.
The Journal of Nutrition, 2009. 139(9): p. 1744-1750.
W Moumena, et al., Prevalence of anemia and the dietary intake of children
ages 5-9 in Trinidad and Tobago, in 58th Annual CHRC/CARPHA Scientific
Conference, C.H.R.C. (CHRC), Editor. 2012, West Indian Medical Journal:
Caribbean.
Pasricha, S.-R., et al., Determinants of anemia among young children in rural
India. Pediatrics, 2010. 126(1): p. e140-e149.
Khatib, L.A., et al., Folate deficiency is associated with nutritional anaemia in
Lebanese women of childbearing age. Public Health Nutrition, 2006. 9(07): p.
921-927.