Original Article
Prevalence and risk factors of iron‑deficiency
anemia in Saudi female medical students
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Mona Hmoud AlSheikh
Department of Physiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Address for correspondence:
Dr. Mona Hmoud AlSheikh,
Admin Bldg. (400), 2nd Floor,
ABSTRACT
King Fahd University Hospital,
Aqrabia, Alkhobar,
P.O. Box: 2208 Alkhobar 31952,
Saudi Arabia.
E‑mail: monaalsheikh@gmail.com
INTRODUCTION
Higher hemoglobin (Hb) levels are associated with improved
performance and quality of life (QOL). Its deficiency,
known as anemia, causes poor pregnancy outcome,
suboptimal learning and cognitive function, disturbed
behavior, poor attention, and growth issues in the affected
individuals.[1] The definition of anemia as explained by the
World Health Organization (WHO) and most frequently
used in epidemiologic studies is when Hb concentration
is <12 g/dL in women and 13 g/dL in men.[2] Anemia is a
common but multifactorial condition which continues to be a
problem in the developing world. Approximately one‑quarter
of the world’s total population is suffering from anemia. In
teenage and early adulthood only, the WHO estimates the
prevalence of anemia to be 22.6%–54.0%.[2]
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DOI:
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148
Introduction: Iron‑deficiency anemia (IDA) is quite common in female adolescents and adults
worldwide. Despite the higher prevalence of IDA, there is a paucity of research in finding
its prevalence and potential causes in young Saudi female population. Thus, the aim of this
study was to determine the prevalence and possible causes of IDA in young female medical
students and search for risk factors in the studied group. Materials and Methods: One hundred
and twenty female students from Imam Abdulrahman Bin Faisal University were selected by
randomized sampling whose blood samples were taken to measure their hemoglobin (Hb)
and serum ferritin levels. According to the World Health Organization criteria, individuals
with Hb <12 g/dL and ferritin <15 ng/mL were considered anemic. The sociodemographic,
gynecological, and dietary data were collected from all the respondents with the help of
a well‑designed 15 items questionnaire. The association between IDA and the potential
risk factors was found through Fishers’ exact test or Chi‑square test. Results: Among the
studied group, 38.3% of total population were anemic. Mean Hb ± standard deviation (SD)
was found to be 12.6 ± 1.3 and mean ferritin ± SD was 18.9 ± 5.2. No statistically significant
correlation (P > 0.05) was found between IDA and the background, gynecological history,
and dietary habits of the anemic participants. Conclusions: The higher prevalence rate of
anemia among Saudi female medical students (38.3%) was similar to the earlier reports of
the Gulf region. Considering the higher ratio of anemic students, iron supplements should be
prescribed to the affected youngsters to improve their Hb level.
Key words: Dietary habits, iron‑deficiency anemia, medical students, menstruation cycle
Anemia has many types, and among them, iron‑deficiency
anemia (IDA) has the highest prevalence. [3,4] In many
developing countries, it has reached to an epidemic level[5] and
is recorded as the most prevalent micronutrient deficiency in
the world.[6,7] Its deficiency has remarkable negative effects
on the suffering individuals. Among the commonly known
negative outcomes, impaired mental and physical growth,
poor motor function, diminished work capacity, and an overall
poor QOL are the most pronounced ones.[8]
The most common cause of ID is a prolonged negative
imbalance between its dietary intake and the physiological
demand of the person.[8,9] Studies suggest that there are
numerous factors that influence the iron balance in a human
body. These factors, either in combination or alone,[10] could
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How to cite this article: AlSheikh MH. Prevalence and risk factors of iron-
deficiency anemia in Saudi female medical students. Saudi J Health Sci
2018;7:148-52.
© 2019 Saudi Journal for Health Sciences | Published by Wolters Kluwer - Medknow
 Alsheikh: Prevalence and risk factors of anemia in females
be sociodemographic in nature (age, sex, marital status,
education level, ethnicity, and financial status) or related
to food intake, mental and physical health, consumption of
medication or genetic makeup of the suffering individuals.[11,12]
Within the affected adults, females suffer from anemia the
most. A recent study reported the prevalence rate of anemia
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to be 58.9% in Saudi Arabian women.[13] This prevalence rate is
considerably higher as compared to the findings of Rasheed
et al.[14] who reported 41.3% prevalence rate in Saudi females.
The greater number of affected females shows increased
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prevalence rate over this period of time.
In young IDA inflicted females, it causes lifelong effects on
the affected individuals such as poor maternal and neonatal
outcomes and pronounced risk of disability in their lives
ahead.[15] Despite its severity and unfortunate after effects,
the latest information on the prevalence and the associated
risk factors of IDA are scarce in the context of young Saudi
females. Few studies have reported the prevalence of IDA in
Saudi females; however, the potential risk factors associated
with IDA were mostly not the focus of these studies, especially
in the eastern region.[16] Due to this gap in the literature, this
study aimed to evaluate the causes and risk factors of IDA
among female youngsters and also intended to report any
significant risk factor associated with this condition.
MATERIALS AND METHODS
Subjects
It was a cross‑sectional observational study which was
done between June and November 2017. Through random
sampling, a total of 120 otherwise healthy female students
were selected who were studying at Imam Abdulrahman Bin
Faisal University. Those female students who had a reported
eating disorder, pregnancy, breastfeeding, or a history of
medication/nutritional supplements were excluded from
the study. After explaining the purpose of investigation, an
informed consent was obtained from all the participants.
The confidentiality of their personal details and study
results was ensured. The ethical approval for this study was
obtained from the ethics and research committee of Imam
Abdulrahman Bin Faisal University.
Data collection
Before blood sampling, students were also asked to fill
a questionnaire of 15 items to obtain their personal and
demographic data. The structured questionnaire was based
on the prior literature and was recently used and pilot
tested by Riyadh and Osama.[11,17‑19] The three major domains
covered in the questionnaire were the information regarding
the personal sociodemographic data (marital status,
mother’s education level, and family history of anemia);
gynecological and obstetric history (age of menarche,
length of cycle, duration of menstruation, the presence of
clot, history of flooding, and chronic bleeding); and dietary
Saudi Journal for Health Sciences - Volume 7, Issue 3, September-December 2018
habits (intake frequency of breakfast, meat, vegetables,
Vitamin C, and drugs). Approximately 15 min were taken by
each participant to fill the required information.
Blood sample collection
The blood sample collection was done on campus for the
convenience purpose. A sample of venous blood (10 mL)
was collected from each student on the same day when the
questionnaire was filled by them. The vacutainers, which
were used to perform venipunctures, were of two types, one
had ethylenediaminetetraacetic acid in it for hematological
tests including Hb, mean corpuscular Hb, hematocrit, mean
corpuscular Hb concentration, and mean corpuscular volume.
Beckman Coulter LH750 machine was used to perform these
tests. For biochemical screening, vacutainers were used
without the addition of any anticoagulant. The purpose was
to allow the blood sample to clot while it was assigned to a
serum separator. A modular machine was used to calculate
serum iron, ferritin, and total iron capacity.
Data analysis
The statistical analysis was performed by Statistical
Package for the Social Sciences (SPSS) version 22 (SPSS Inc,
Chicago, IL, USA). The results were presented as number and
percentage. Fishers’ exact test or Chi‑square test was used
for testing the association between anemia and its potential
predictors. During analysis, the participants were gathered
into anemic or nonanemic groups according to the WHO
criteria. Participants with Hb <12 g/dL and ferritin <15 ng/
mL were considered to possess IDA.[20] Value of P < 0.05 was
considered to be statistically significant.
RESULTS
According to the WHO classification, it was found that
46 female students (38.33%) had anemia and 74 (61.67%) had
normal Hb and ferritin levels. Mean ± standard deviation (SD)
of Hb was found to be 12.6 ± 1.3 and mean ferritin ± SD was
18.9 ± 5.2. The age range of the participants was from 18
to 24 years with a mean age of 20.2 years. The mean age of
menarche was 12.8 years. The mean length of the menstrual
cycle was 27 days and mean duration of menstruation was
6.6 days. A proportion of 16.7% of students had a history of
flooding and 53.3% of students had a history of clots. Only
four students were married. Positive family history of anemia
was found in 45% of participants and 5% had a history of
chronic bleeding. Tables 1‑3 show the distribution of IDA
according to students’ background, gynecological history,
and dietary habits, respectively. In all the cases, a significant
association between anemia and included variables could
not be found.
DISCUSSION
The objective of the current study was to estimate the
prevalence of IDA among Saudi female students and to find
149
 Alsheikh: Prevalence and risk factors of anemia in females

Table 1: Distribution of iron‑deficiency anemia according reported at 9%.[23] One such example can be seen in an Indian
to students’ background study which reported 44% prevalence of anemia among female
Variables Anemic P students.[24] Similarly, IDA, which is an anemic condition, has
Yes (%) No (%) also been detected at higher rate among female students in
Marital status other developing countries. In a study, Shill et al. found IDA
Married 0 4 (100.0) 0.519 in 63.3% of Bangladeshi female students.[25] On the contrary,
Unmarried 46 (39.7) 70 (60.3) in developed countries such as Australia, only 3% female
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Mother’s education level university students were found to be suffering from IDA.[21]
Elementary 4 (33.3) 8 (66.7) 0.430 In local Saudi context, the prevalence of IDA (38.33%) found
Preparatory 2 (100.0) 0 (0.0) in the current study is significantly lower as compared to
Secondary 8 (40.0) 12 (60.0) previous study which reported 64% prevalence of IDA.[16]
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College 2 (14.3) 12 (85.7) Interestingly, in a recent study, Alzaheb and Al‑Amer[26] have
Masters 10 (31.2) 22 (68.8) reported the prevalence of anemia to be 12.5% in female
PhD 20 (50.0) 20 (50.0) students which are significantly lower than the current
Family history of anemia findings.
Yes 20 (37.0) 34 (63.0) 0.227
No 26 (39.4) 40 (60.6) Current findings showed that female students who were
anemic reported lower consumption of meat. The heme
form of iron is largely found in meat which has an absorption
Table 2: Distribution of iron‑deficiency anemia according rate of 50%.[27] The nonheme iron type is typically found in
to gynecological history fruits, vegetables, and dairy products.[28] Meat consumption
Variables Anemic P plays a vital role in preventing IDA. Many existing studies
Yes (%) No (%) strongly suggest a negative correlation between low
Age of menarche meat consumption and increased chances of IDA.[11,18] One
<12 12 (35.3) 22 (64.7) 0.135 contributing factor toward less consumption of meat could
12-15 26 (34.2) 50 (65.8) be the low socioeconomic background. The meat is relatively
>15 8 (80.0) 2 (20.0) costly that can prevent families of humble background to
Length of cycle consume it on daily basis.[29] Işık Balcı et al. reported that
<28 14 (28.0) 36 (72.0) 0.391 families with poor background consume red meat and fish
28-32 26 (44.8) 32 (55.2) which result in less intake of iron.[30]
>32 2 (25.0) 6 (75.0)
Duration of menstruation (days) The iron intake is not the only contributing factor in
<5 4 (66.7) 2 (33.3) 0.364 decreasing the chances of IDA. There are other dietary factors
5-7 30 (34.1) 58 (65.9) which enhance or inhibit the iron absorption, one such factor
>7 12 (50.0) 12 (50.0) is Vitamin C intake.[31] Vitamin C (ascorbic acid), found in citrus
Presence of clots in menstruation fruits, has already been reported as an enhancer for iron
Yes 18 (28.1) 46 (71.9) 0.112 absorption found in nonheme foods.[32,33] Previous research
No 28 (50.0) 28 (50.0) has associated low citrus fruit consumption with an elevated
History of flooding risk of anemia.[10] In this study, the effect of Vitamin C intake
Yes 2 (10.0) 18 (90.0) 0.073 on the absorption and bioavailability of iron has also been
No 44 (44.0) 56 (56.0) calculated. While doing so, it was found that most reported
Chronic bleeding cases of IDA had inadequate intake of Vitamin C. However,
Yes 2 (33.3) 4 (66.7) 0.109 the negative correlation was not statistically significant.
No 44 (38.6) 70 (61.4)
In the current findings, IDA showed no statistically significant
association with the sociodemographic gynecological
the potential risk factors which could be associated with IDA.
variables which are in line with a recent study conducted by
The rationale to include female students was that they are at Alquaiz et al.[11] However, this finding is in contrast to some
higher risk of ID as compared to general population because prior studies which have been conducted in Saudi context
of menstrual blood loss, pregnancy, and/or lactation.[21,22] and have reported that IDA has a significant relationship
with past personal, medical, and/or gynecological history of
Anemia is a commonly known and widespread condition, but the participants.[18]
its prevalence differs in developing and developed countries.
For instance, 43% of total population is suffering from Limitations
anemia in developing countries whereas its prevalence rate In the present study, there are some limitations to report.
is significantly lower in highly developed countries which is First, this study was quantitative in nature and is unable to

150 Saudi Journal for Health Sciences - Volume 7, Issue 3, September-December 2018
 Alsheikh: Prevalence and risk factors of anemia in females

Table 3: Distribution of iron‑deficiency anemia according Conflicts of interest

to dietary habits There are no conflicts of interest.
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