2016 (Txt8) Prevalence of Iron Deficiency Anemia amongst a Subset of Female Students at Aljouf University, Sakaka, Saudi Arabia Abstract Background: The frequency and causes of anemia are largely unknown particularly amongst females in the northern Al-Jouf Saudi region. Objectives: Prevalence of iron deficiency anemia (IDA) in voluntarily participating healthy female university students at the College of Applied Medical Sciences of Aljouf University, Sakaka, Saudi Arabia was assessed in a prospectively planned cross- sectional study. Participants and Methods: 198 students were enrolled in the study carried out in the period between October and December 2015. Serum and whole peripheral venous blood samples on EDTA were collected for assessment of full blood count (FBC) and serum ferritin level. Results: Anemia was diagnosed in 32% of participants (n = 64/198). Mild (Hb 10 – 11.7 g/dL), moderate (Hb 8 – 10 g/dL) and severe microcytic anemia (Hb <8 g/dL), and, normocytic anemia (Hb ≥11.8 g/dL) constituted 24.4%, 3.0%, 1.5% and 2.5%, respectively. As their mean ferritin level was significantly lower than normal controls (6.9 vs. 96.3 ng/mL; p<0.01), their anemia was confirmed as IDA rather than other anemia with microcytic picture. A high MCV level (MCV = 97 fL, Hb = 10 g/dL) with a normal ferritin level (120.5 ng/mL) made the diagnosis of a macrocytic anemia in only one participant. Conclusion: Our results showed a high rate of IDA among Saudi university females studied. This implicates pathogenetic factors related to nutrition and lifestyle habits. In an area with popular early marriage, an intervention is mandatory to avoid risk and complications of IDA on adult females and expected newborns. Key Words: Iron deficiency anemia, Ferritin, Female university students, Microcytic anemia, Macrocytic anemia, Sakaka, Saudi Arabia. Citation: Elderdery AY, Alshaiban AS, Abdelgadir AA, Elhussein DM, Alnemer MA, Alkhelaiwi WA, Alshamikh YS, Alruwaili AS, Alfaleh BM, Alqyadh DI. Prevalence of Iron Deficiency Anemia amongst a Subset of Female Students at Aljouf University, Sakak, Saudi Arabia. AUMJ, September 1, 2016; 3 (3): 23 - 27. Introduction Normal hemoglobin (Hb) concentration is crucial to supply the body’s vital organs with the required oxygen to function properly. Low Hb concentration causes anemia, which is a common blood disorder worldwide and may threaten life as many individuals (1, 2). The World Health Organization (WHO) reported that 150 million individuals of Eastern Mediterranean origin suffer from (3, 4). One third of individuals throughout the world (over 2 billion individual) have had iron deficiency anemia (IDA) (5) . In contrast, Saudi Arabia is reported as having frequency varying degrees of IDA between 30 – 56% (6). A cross-sectional study conducted on female students at the Medical Center of Taibah University showed that the prevalence of anemia was 65.4% (7). Another study also reported that the frequency of anemia was 40.5% in female adolescents (16-18 Yrs) of Riyadh City (8). No studies have been undertaken on in Al-Jouf region to study the prevalence and causes of IDA despite its public (9, 10). Therefore, the current study aimed to estimate the prevalence of IDA among a representative sample of Aljouf female university students belonging to College of Applied Medical Sciences, Sakaka, Saudi Arabia. Participants and Methods The present study was carried out in the Haematology Laboratory of the College of Applied Medical Sciences, Aljouf University and the Prince Moteb Bin AbdulAziz Hospital, Sakaka, Saudi Arabia, as a cross-sectional descriptive study with an internal comparison group during the period from October, 2015 to January, 2016. In this study, no-probability sample equation was used to determine sample size (11), but for feasibility reasons all the willingly volunteering females were enrolled comprising one hundred and ninety eight participants to participate in the current study. Females already on medications for anemia and other diseases and pregnant or lactating females were excluded from the study. A data collection sheet was designed to collect age, family history and past clinical data. Ethical approval was obtained for this study and written informed consent was given by each participant prior to collection of the specimens. This project was done among females, as IDA was found to be highly prevalent among them in other parts of Saudi Arabia (8, 12). For complete blood count (CBC) analysis using Mindray 320 hematology analyzer, peripheral venous blood (5 mL each patient) was collected on EDTA. Serum ferritin assessment using a Beckman Coulter Chemistry Analyzer required a separated sample (3 mL) collected in plain tubes for serum recovery. SPSS version 20 was used to compare and correlate FBC parameters and ferritin levels among patients with anemias against non-anemic individuals. Data were presented as frequency and mean ± SDM along the p value. Results Sixty four participants of our study population (32%) were found to be anemic. Of the anemic cases, the vast majority of them suffered microcytic hypochromic anemia accounting for 90.6%. In terms of the severity, these cases of microcytic hypochromic anemia were subclassified into mild (Hb = 10 – 11.8 g/dL), moderate (Hb = 8 – 10 g/dL) and severe (Hb <8 g/dL), and they constituted 84.5%, 10.3% and 5.2%, respectively of the microcytic anemic participants. The mean ferritin levels of the 4 micro- and normocytic anemic groups were 11, 9, 4.8 and 2.6 ng/mL, respectively, which was significantly lower (p<0.01) than the healthy control group (96.3 ng/mL). Accordingly, all these groups were diagnosed with iron deficiency (IDA) rather than other diagnoses with microcytic picture. All anemic groups with low ferritin levels were microcytic (MCV = 74 ± 4 fL), significantly lower (p<0.01) than the control group (MCV = 84.1 ± 5.7 fL). The normocytic group also had significantly lower MCV (81 ± 1.0 fL; p<0.05) in comparison with the control group. Macrocytic anemia was observed in only one participant with high MCV fL, Hb =10 g/dL and ferritin level = 120.5 level and normal ferritin level (MCV = 97 ng/mL; Table 1). Discussion Recent published studies indicate in Saudi Arabia that IDA is common among female university students, particularly in Riyadh and Al-Madinah Al-Munawarah cities and other parts of Saudi Arabia (7, 13). Currently, little is known about the frequency of the types of IDA and its causes among Aljouf female university students, in part because of the scarcity of research and a dearth of data on prevalence of anemia in general in this region. Therefore, this study was aimed to detect the frequency and types of IDA in healthy university female students attending College of Applied Medical Sciences of Aljouf University with the exception of those already on medications for anemia and other diseases, or pregnant or lactating. One third of the study sample (n = 64; 32%), were found to be anemic. In comparison with other studies from Saudi Arabia, anemia was detected at higher frequency among female students of Riyadh ( and Al-Madinah Al- Munawarah ( Even worse, the frequency of anemia among women in third world countries and worldwide are 75% and 41.8%, respectively (14,15). Globally, WHO recently documented that the rate of anemia among adolescent students was 25.4% (16), which was lower than our finding. However, unlike this study, The WHO study involved both genders. IDA is described as microcytic anemia with low MCV, but a differential diagnosis must be done to distinguish IDA from other microcytic anemias with low MCV; for instance thalassemia (β and α), sideroblastic, some types of anemia of chronic disease and lead poisoning. Serum ferritin is recommended as an initial and confirmatory diagnostic test in case of low level for diagnosing patients with IDA. Serum iron, transferrin saturation, total iron-binding capacity and serum transferrin receptor levels may be additionally useful if the ferritin level is between 46 - 99ng/mL. Bone marrow examination may be crucial for a definitive diagnosis in these above mentioned haematological disorders (17). Individuals with IDA in the current study were easily diagnosed based on the results of two hematological parameters, MCV and serum ferritin without needing further investigations, as their MCV was below 80fL and serum ferritin less than 11 ng/mL. In our participants, IDA was found to be most frequent at ~31.4% of the targeted population. They were categorized into four categories based on Hb concentration as follows: mild IDA (10 – 11.8 g/dL), moderate IDA (8 – 10 g/dL), and severe IDA (Hb <8 g/dL) comprising 24.4%, 3%, 1.5% and 2.5%, respectively, along with normocytic IDA with low ferritin level. All these groups were classified as IDA, as their Hb, MCV and ferritin level were significantly low (p <0.01) compared to the normal group, although the average of MCV level in the normocytic group was in the marginal lower normal range. This result is in agreement with studies in other areas of Saudi Arabia, in which IDA has been reported at a frequency between 30-56% (18). In developing countries, 75% of anemia is IDA, affecting about 30% of individuals. Therefore, the rate of IDA in our study population is considered high among adolescent females. Only one case of anemia in this study was macrocytic. Her MCV was significantly higher compared to the non-anemic group. Accordingly, macrocytosis in such a case is marginal and unlikely attributable to megaloblastic anemia and therefore it may be due to other causes of macrocytosis (19,20). High prevalence of IDA was not unexpected in Al-Jouf region, as it has been detected before in this country (21). High frequency of IDA with varying degrees of severity have been reported in adult age groups in several areas of Saudi Arabia, including Riyadh, eastern, south- western and western parts of the country (22, 23), while IDA was found in our study population, as 98.5% of anemic patients had low ferritin levels (6.9ng/mL) and therefore the possible diagnosis of them was IDA and one patient had microcytic anemia. Moreover, results of FBC and blood morphology of participants with low Hb concentration were helped to exclude other types of anemias. Additionally, the data collected as family history and past clinical data assisted us to classify our anemic patients. Conclusion IDA but not other types of anemia prevailed among the study female university students. This could be ascribed to their nutritional factors and life style habits - very risky in such a child-bearing age in a culture where early marriage is popular. Iron supplementation program should be instigated for females of the region - where illiterates and those with lower education levels from the same age group are expected to have worse situation. Limitations of the Study • We wished analyzing data of a larger sample. However, this was the maximum participation rate we could get. • A comparison to other females of the child-bearing age from different socioeconomic and rural/urban background could have revealed distinct figures. This was planned for. Acknowledgement This study is funded by a generous fund from the Deanship of Scientific Research and Postgraduate Studies, Aljouf University, Sakaka, Saudi Arabia (Project No. 35/4342).