754 La Revue de Santé de la Méditerranée orientale, Vol.

10, N o 6, 2004

Invited paper

Iron deficiency anaemia – an old

enemy
K. Bagchi1

SUMMARY Anaemia has remained a widespread public health problem in countries of the Eastern Mediter-
ranean Region. Prevalence figures vary from a low of 17% to a high of over 70% among preschool children;
from 14% to 42% among adolescents and from 11% to over 40% among women of childbearing age.
Although the prevalence of anaemia has often been used as a proxy indicator for iron deficiency anaemia,
this approach is not valid in settings where the etiology of anaemia is complex or unknown or where other
micronutrient deficiencies of folate, vitamin B12 and vitamin A can co-exist. An integrated, multifactorial and
multisectoral approach has to be adopted comprising targeted interventions to provide iron supplements to
especially vulnerable segments of the population, in particular pregnant women; food-based approaches to
increase iron intake through food fortification and dietary diversification; and other measures combined with
iron interventions where other causes of anaemia are prevalent.

Introduction tion to iron deficiency, anaemia also results

from malaria, general inflammatory disor-
Anaemia remains a widespread public ders or nutritional deficiencies of folate and
health problem with major consequences vitamin B12 as well as HIV/AIDS [4].
for human health as well as social and eco-
nomic development. Although estimates of
the prevalence of anaemia vary widely and Anaemia in the Eastern
accurate data are often lacking, it can be Mediterranean Region
assumed that significant proportions of
young children and women of childbearing Over the years, significant progress has
age are anaemic [1,2]. been made in improving the health and nu-
The important health effects of trition status of the people of the Eastern
anaemia, i.e. increased risk of maternal and Mediterranean Region. The proportion of
child morbidity and mortality due to severe underweight, wasted and stunted children,
anaemia, have been well documented. In as well as infant and under-five mortality
addition, the negative consequences of iron rates, have all decreased as a whole, but
deficiency anaemia on the cognitive and with some inter-country variations [5].
physical development of children and on In spite of this development, anaemia,
the work productivity of adults are of ma- particularly attributed to iron deficiency,
jor concern [3]. among infants, preschool children and
Although iron deficiency anaemia re- women of childbearing age has remained a
mains a considerable public health problem, widespread public health problem, irre-
one should also keep in mind that, in addi- spective of the family economic status and

1
Regional Adviser, Nutrition Unit, World Health Organization Regional Office for the Eastern
Mediterranean, Cairo, Egypt.
Eastern Mediterranean Health Journal, Vol. 10, No. 6, 2004 755

income level in most countries of the Re- sistence of anaemia (presumably iron defi-
gion [6]. The overall situation of anaemia in ciency anaemia) in different age groups.
countries of the Region was studied in Among infants from 6 months on-
1995 [7] although the terms anaemia and wards, a high prevalence of anaemia is re-
iron deficiency anaemia were used inter- ported, with iron deficiency anaemia being
changeably. The prevalence rate of anaemia the single most important cause [11,12].
was reported to be moderate in magnitude The prevalence of anaemia in preschool
when compared with other developing re- children has also remained high, varying
gions, which could be partially due to from 29% to over 60% [13,14], although
under-reporting and lack of nationally rep- occasional reports do indicate a decline in
resentative data. A few countries had up-to- the prevalence of anaemia in this age group
date national-level data on anaemia while [13]. Among preschool children, the mag-
available information in the majority of the nitude of anaemia is reported to be associ-
situations was based on ad hoc surveys or ated with birth order (thereby indicating a
small-scale studies on specific population gradual depletion of the iron stores of
groups. mothers after repeated pregnancies), low
The prevalence of anaemia in women of dietary iron intake, socioeconomic status
childbearing age ranged from around 20% and literacy level of mothers [13,14].
in Jordan, parts of Egypt and parts of Among women of childbearing age,
Oman to more than 60% in countries like from both rural and urban backgrounds,
Djibouti. Preschool children were more af- the prevalence of anaemia has ranged be-
fected than women, with reported preva- tween 20% and 70%, again mostly attribut-
lence in excess of 60% in many countries ed to iron deficiency [15–18], in addition to
[7]. Low intake of total dietary iron, pro- deficiencies of folic acid and vitamin B12
portionate high consumption of non-haeme [11]. Income, literacy and family size are
iron, poor iron absorption due to iron- factors that affect total iron intake and
absorption inhibiting factors, such as anaemia status [15]. Women with anaemia
tannins in tea and phytates in unleavened are reported to have high fetal mortality
bread, were identified as the common [19] and deliver babies with lower birth
causes of anaemia, in addition to high birth weight, and low haemoglobin and serum
rates, short birth intervals and concurrent ferritin levels as compared to non-anaemic
parasitic infections. The importance of ge- women in different gestational age groups
netic factors, particularly thalassaemias, [11,17].
remained another possibility but required Most studies on adolescents have re-
further research for any conclusion to be ported prevalence rates for anaemia rang-
drawn [7]. ing from 30% to 55% with the milder form
All subsequent assessments of the pu- of anaemia predominating (>80%) [18–
blic health importance of anaemia carried 23]; occasional reports have indicated im-
out over the next decade have continued to provement in anaemia status in this age
report high prevalence of anaemia, mostly group [23]. The high prevalence of
attributed to iron deficiency [8–10], with anaemia among adolescents has been at-
similar causative factors as reported earlier tributed to increased needs for iron due to
[7]. rapid growth and menarche, low intake of
A review of published studies from iron-rich foods, inappropriate dietary
countries of this Region indicates the per- choices, intestinal parasitic infestation and
756 La Revue de Santé de la Méditerranée orientale, Vol. 10, N o 6, 2004

frequent consumption of tea with meals, all data. Prevalence data of anaemia in a num-
or in various combinations [18,19,22,24]. ber of age categories from several Member
The prevalence of anaemia declined sharply States are also not available. No definite
in boys after the age of 16 years coinciding pattern in the prevalence of anaemia can be
with the end of a growth spurt while the discerned from Table 1 other than the fact
prevalence of anaemia among girls started that anaemia affects all Member States and
to rise after the age of 18 years as they pro- all age groups. Anaemia varied from a low
ceeded to marriage and childbearing of 17% in Saudi Arabia to a high of over
[19,22]. 70% in Yemen among preschool children;
The Nutrition Unit of the World Health from 14% in the United Arab Emirates to
Organization’s Regional Office for the 42% in Pakistan among adolescents; and
Eastern Mediterranean compiled basic in- from a low of 11% in Egypt to over 40% in
formation on the overall nutrition situation the Syrian Arab Republic and Oman among
in the Member States through a question- women of childbearing age. The compara-
naire survey. This information is presented tively low prevalence of anaemia among
in Table 1 [25]. The information does not adult males noted here may be attributed to
identify the different types of anaemia or the high iron intake in the form of meat as
the methodologies used to determine these reported in countries of this Region [26].

Table 1 Prevalence (%) of anaemia in different age groups from selected countries of the
Eastern Mediterranean Region [26]

Country Population group

Infants Children Children Pregnant Lactating Women Adult Elderly
0–6 6–59 5–14 women women of child men (males &
months months years bearing females
age combined)

Bahrain 48.3 41.6 33.5 37.3 20.9 58

Egypt 25 26 19 11
Jordan 8.8 15.3 35 35 28
Islamic Republic
of Iran 15–30 20–43 33.4 7.9–9.9 20–25
Lebanon 23 25
Morocco 35.4 45.5 30.1 9.9
Oman 41 38 40
Pakistan 60 42 45 22.5 30 30
Palestine 52.8 44.7 36.2
Saudi Arabia 14.8 17.2 15.9 18.3 15.8
Syrian Arab
Republic 23 40.8
United Arab
Emirates 34 14 14
Yemen 73.5
Eastern Mediterranean Health Journal, Vol. 10, No. 6, 2004 757

In Table 2, information from 1995 [7] women of childbearing age, while the hae-
and 2002/2003 [25] is compared. In spite moglobin levels were within normal range,
of the lack of matching information in sev- serum ferritin levels were low, thereby indi-
eral age categories between 1995 and 2002, cating that haemoglobin was not a sensitive
it would seem that the prevalence of measure of iron deficiency [27].
anaemia has not changed over the years. A cross-sectional study of Bahraini
Member States have become aware of women in the age group 14–49 years was
this persisting public health problem and in carried out in early 2002, 6 months after
recent years some efforts have been made the initiation of the national programme of
to identify the prevalence of anaemia with fortifying wheat flour with iron and folic
precision through national anaemia/micron- acid [29]. Using the dual criteria of haemo-
utrient surveys. The national survey on globin and serum ferritin, the survey re-
anaemia in Jordan in late 2002 reported that ported that the prevalence of overall
20.3% of children between 12 and 59 anaemia was 51.3% among the women,
months of age were anaemic, 50% of 24.5% of which was due to iron deficien-
whom had iron deficiency anaemia [28]. In cy. The authors concluded that there was
women of childbearing age, the prevalence no significant difference in the prevalence
of anaemia was 32.3% with 70% of of anaemia between this survey and the na-
anaemia being due to iron deficiency; the tional nutrition survey conducted before
survey did not identify the other causes of the initiation of the national fortification
anaemia. The survey also reported that in programme [28].
children between 12 and 59 months and in

Table 2 Comparison of anaemia prevalence (%) between 1995 and 2002/2003 in

selected countries of the Eastern Mediterranean Region [7,26]

Country Children 6–59 Pregnant women Women of

months childbearing age
1995 2002 1995 2002 1995 2002

Bahrain 34 48.3 33.5 40 37.3

Egypt 75–90 25 21–5 26 11
Jordan 35 23.4 28
Islamic Republic of Iran >30 15–30 20–50 20–43 33.4
Lebanon 23
Morocco 27–47 35.4 20 45.5 30.1
Oman 60 54 38 15–48 40
Pakistan 65 60 45 22.5
Palestine 58–76 52.8 23–44 44.7 36.2
Saudi Arabia 14.9 11–19 15.9 18.3
Syrian Arab Republic 53 23 49 40.8
United Arab Emirates 28–76 34 22–62 14
Yemen 17–66 73.5 5–36
758 La Revue de Santé de la Méditerranée orientale, Vol. 10, N o 6, 2004

Conclusions berculosis and HIV/AIDS are important

factors contributing to the high prevalence
Greater food availability does not necessar- of anaemia in many populations [2,30–32].
ily equal better nutrition or health status. The recent joint statement by the World
Nowhere can this be better demonstrated Health Organization and the United Nations
than in the case of anaemia, which contin- Children’s Fund on an integrated approach
ues to occur in all strata of people in Mem- for effective anaemia control [2] states that
ber States of the Eastern Mediterranean “only by recognizing the complexities asso-
Region [2,25,28]. ciated with anaemia can effective strategies
Because of the comparative ease of de- be established and progress made.”
termination of haemoglobin concentration, The integrated, multifactorial and multi-
the prevalence of anaemia has often been sectoral approach mentioned in the joint
used as a proxy indicator for iron deficien- statement will comprise: targeted interven-
cy anaemia [2,29]. While this approach tions to provide iron supplements to espe-
may be useful where iron deficiency is cially vulnerable segments of the
known to be the major cause of anaemia, it population, in particular pregnant women;
is not valid in settings where the etiology of food-based approaches to increase iron in-
anaemia is complex or unknown or where take through food fortification and dietary
other micronutrient deficiencies that can diversification; other measures combined
cause anaemia co-exist. Other nutritional with iron interventions where other causes
deficiencies other than iron, such as folate, of anaemia are prevalent; integration of in-
vitamin B12 and vitamin A, can also cause tervention strategies into the existing pri-
anaemia, although the magnitude of their mary health care system and existing
contribution is unclear [2,11,27]. In addi- national food and nutrition programmes.
tion, the impact of haemoglobinopathies on Such an approach will be evidence-based
anaemia prevalence needs to be considered and take into account the specific etiology
among some populations [2,7]. Infectious and prevalence of anaemia in a given setting
diseases, in particular malaria and helminth and population group [2].
infections, and other infections such as tu-

References
1. Iron deficiency anaemia: assessment, plications for research and programs.
prevention and control. Geneva, World Journal of nutrition, 2001, 131(suppl.
Health Organization, 2001. 2):697S–701S.
2. Focusing on anaemia: towards an inte- 4. Solomons NW. All that glitters is not iron
grated approach for effective anaemia (deficiency): revisiting the question of
control: joint statement by the World why anaemic individuals are anaemic.
Health Organization and the United Na- Nutrition reviews, 2002, 60(3):91–6.
tions Children’s Fund. Geneva, World
5. De Onis M, Blossner M. Is malnutriton
Health Organization, 2004.
declining? An analysis of changes in
3. Stolzfus RJ. Iron-deficiency anaemia: re- levels of child malnutriton since 1980.
examining the nature and magnitude of Bulletin of the World Health Organiza-
the public health problem. Summary im- tion, 2000,78:1222–33
Eastern Mediterranean Health Journal, Vol. 10, No. 6, 2004 759

6. Aoyama A. Towards a vicious circle: a 14. El-Sayed N et al. Assessment of the

nutrition review of the Middle East & prevalence and potential determinants
North Africa. Washington DC, The World of nutritional anaemia in Upper Egypt.
Bank, 1999. Food & nutrition bulletin, 1999, 20(4):
417–21.
7. Verster A, van der Pols JC. Anaemia in
the Eastern Mediterranean Region. 15. Djazayery A et al. Iron status and socio-
Eastern Mediterranean health journal, economic determinants of the quantity
1995, 1(1):64–79. and quality of dietary iron in a group of
rural Iranian women. Eastern Mediterra-
8. World Health Organization Regional Of-
nean health journal, 2001, 7(4/5):652–7.
fice for the Eastern Mediterranean and
United Nations Children’s Fund. Techni- 16. Arafa M et al. Maternal haemoglobin and
cal consultation to develop guidelines premature child delivery. Eastern Medi-
for the control of iron deficiency in coun- terranean health journal, 1998, 4(3):
tries of the Region. Alexandria, World 480–6.
Health Organization Regional Office for
17. Ziaei S, Hatefnia E, Togh Gh. Iron status
the Eastern Mediterranean, 1995.
in newborns born to iron-deficient moth-
9. World Health Organization Regional Of- ers. Iranian journal of medical sciences,
fice for the Eastern Mediterranean, 2002, 28 (2):62–4.
United Nations Children’s Fund and Mi-
18. Joharah MA, Al-Quaiz. Iron deficiency
cronutrient Initiative. Fortification of flour
anaemia: a study of risk factors. Saudi
with iron in countries of the Eastern
medical journal, 2001, 22(6):490–6.
Mediterranean, Middle East & North Af-
rica. Alexandria, World Health Organiza- 19. El-Sahn F et al. Anaemia among Egyp-
tion Regional Office for the Eastern tian adolescents: prevalence and deter-
Mediterranean, 1996. minants. Eastern Mediterranean health
journal, 2000, 6(5/6):1017–25.
10. Flour fortification: reporting accomplish-
ments. Report of a joint WHO/UNICEF/MI 20. Egypt’s Adolescent Anaemia Prevention
intercountry technical review meeting on Programme (a report on programme de-
flour fortification. Cairo, World Health Or- velopment, pilot efforts and lessons
ganization Regional Office for the East- learned). Cairo, Ministry of Health &
ern Mediterranean, 2001. Population/Health Insurance Organiza-
tion/USAID/JSI/Manoff Group, 1998.
11. Kilbride J et al. Iron status, serum folate
and B12 values in pregnancy and post- 21. Curtale F et al. Anaemia among young
partum: report from a study in Jordan. male workers in Alexandria, Egypt. East-
Annals of Saudi medicine, 2000, 20(5/ ern Mediterranean health journal, 2000,
6):371–6. 6(5/6):1005–16.
12. Abdel-Wahab A et al. Validity of red 22. Al-Sharbatti SS, Al-Ward NJ, Al-Timmi
blood indices in screening for iron defi- DJ. Anaemia among adolescents. Saudi
ciency anaemia in exclusively breastfed medical journal, 2003, 24:189–94.
infants. Suez Canal University medical
23. Raja’a YA et al. Nutritional status of
journal, 2000, 3(1):49–57.
Yemeni schoolchildren in Al-Malweet
13. Amine EK, Al-Awadi FA. Nutritional sta- Governorate. Eastern Mediterranean
tus survey of pre-school children in Ku- health journal, 2001, 7(1/2):204–10.
wait. Eastern Mediterranean health
journal, 1996, 2(3):386–95.
760 La Revue de Santé de la Méditerranée orientale, Vol. 10, N o 6, 2004

24. Mousa ZA et al. A comparison of se- monitoring study). Kingdom of Bahrain,

lected nutrient intakes in anaemic and Nutrition Section, Public Health Director-
non-anaemic adolescent girls in Kuwait. ate, Ministry of Health, 2003.
Nutrition research, 2003, 23:425–33.
29. Stoltzfus RJ. Defining iron deficiency
25. Questionnaire survey. Cairo, Nutrition anaemia in public health terms: a time for
Unit, World Health Organization Re- reflection. Journal of nutrition, 2001,
gional Office for the Eastern Mediterra- 131:565S–7S.
nean, 2002.
30. Al-Omar IA, Oluboyede OA. Serum fer-
26. Al-Buhairan AM, Oluboyede OA. Deter- ritin and iron parameters in patients with
mination of serum iron, total iron-binding pulmonary tuberculosis. Saudi medical
capacity and serum ferritin in Saudi journal, 2002, 23(2):244–6.
adults. Annals of Saudi medicine, 2001,
31. Staubi Asobayire F et al. Prevalence of
21(1–2):100.
iron deficiency with and without concur-
27. Preliminary report on the national rent anaemia in population groups with
baseline survey on iron deficiency high prevalence of malaria and other in-
anaemia and vitamin A deficiency. fections: a study in Côte d’Ivoire. Ameri-
Amman, Jordan, Ministry of Health, Au- can journal of clinical nutrition, 2001,
gust 2003. 74:776–82.
28. Al-Dallal ZS, Hussain KM. Impact of the 32. Van den Broek NR, Letsky EA. Etiology
national flour fortification program on the of anaemia in pregnancy in south
prevalence of iron deficiency and Malawi. American journal of clinical nu-
anaemia among women at reproductive trition, 2000, 72:247S–56S.
age in the Kingdom of Bahrain (first