Objective: To assess the prevalence of iron deficiency, anaemia and iron deficiency

anaemia (IDA) in women aged 20-40 years and its association with iron intake. Methods:

A total of 388 women were recruited from universities and work sites in Kuala Lumpur and

its suburbs. The subjects comprised 135 Malays, 130 Chinese and 123 Indians. Dietary

intake was estimated using a single 24-hour food recall and a semi-quantitative food frequency

questionnaire. Haemoglobin (Hb), haematocrit (hct), mean corpuscular volume (MCV)

and serum ferritin were determined. Results: The prevalence of anaemia (Hb <12g/dL)

was 20.9%, being highest among the Indians (26.4%) and lowest among the Malays (16.4%).

About 10.3% of the women showed iron deficiency anaemia (IDA) (Hb <12g/dL + serum

ferritin < 15μg/L + MCV <80fl/). The prevalence of IDA was highest in Indians (18.0%)

followed by Chinese (9.9%) and Malays (4.3%). The mean (95%CI) intake of total iron

was at 14.4 mg/day (95% CI 13.4, 15.5), amounting to 49.7% of the Malaysian

recommended nutrient intake (RNI). Intake of iron was the highest for the Indians (16.0

mg/d) and the lowest for the Chinese (11.3 mg/d). Conclusions: The overall prevalence of

IDA was lower compared to prevalence of anaemia. Nonetheless, the markedly higher

prevalence of IDA among the Indians, despite relatively higher intake levels of iron-rich

foods warrants further investigations, including the bioavailability of iron in the context of

cultural practices that may influence food preferences and meal preparation

Khor, Geok Lin

Loh, Su Peng

Universiti Putra Malaysia Institutional Repository

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010Iron Intake and Iron Deficiency Anaemia among Young Women in Kuala Lumpur 63Malaysian Jou nal of Medicine a d Health Sciences Vol. 6(1) January 2010: 63–70Iron Intake and Iron Deficiency Anaemia among Young Women inKuala LumpurSP Loh  & GL KhorFaculty of Medicine and Health Sciences, Universiti Putra Malaysia43400 UPM Serdang, Selangor, MalaysiaABSTRACTObjective:  To assess the prevalence of iron deficiency, anaemia and iron deficiencyanaemia (IDA) in women aged 20-40 years and its association with iron intake.  Methods:A total of 388 women were recruited from universities and work sites in Kuala Lumpur andits suburbs.  The subjects comprised 135 Malays, 130 Chinese and 123 Indians.  Dietaryintake was estimated using a single 24-hour food recall and a semi-quantitative food frequencyquestionnaire.  Haemoglobin (Hb), haematocrit (hct), mean corpuscular volume (MCV)and serum ferritin were determined.  Results:  The prevalence of anaemia (Hb <12g/dL)was 20.9%, being highest among the Indians (26.4%) and lowest among the Malays (16.4%).About 10.3% of the women showed iron deficiency anaemia (IDA) (Hb <12g/dL + serumferritin < 15μg/L + MCV <80fl/).  The prevalence of IDA was highest in Indians (18.0%)followed by Chinese (9.9%) and Malays (4.3%).  The mean (95%CI) intake of total ironwas at 14.4 mg/day (95% CI 13.4, 15.5), amounting to 49.7% of the Malaysianrecommended nutrient intake (RNI).  Intake of iron was the highest for the Indians (16.0mg/d) and the lowest for the Chinese (11.3 mg/d).  Conclusions: The overall prevalence ofIDA was lower compared to prevalence of anaemia.  Nonetheless, the markedly higherprevalence of IDA among the Indians, despite relatively higher intake levels of iron-richfoods warrants further investigations, including the bioavailability of iron in the context ofcultural practices that may influence food preferences and meal preparation.Keywords: Anaemia, iron deficiency anaemia, iron intake, womenINTRODUCTIONThe World Health Organization[1] estimated that about 40% of the world’s population (morethan 2 billion individuals) suffers from anaemia.  The prevalence of iron deficiency (ID),which is usually detected by low serum ferritin concentrations, is estimated to be from 2.0 to2.5 times the prevalence of anaemia.[2]  Iron deficiency anaemia (IDA) occurs when ID issufficiently severe to diminish the production of haemoglobin. Health consequences ofIDA have been observed in infants and children,[3, 4] adolescents[5] and pregnant women[6,7].In the latter, IDA consequences include premature birth, low birth weight and small forgestational age of the newborn.[8]Whilst there are many studies on anaemia in Malaysia, there is a relative dearth ofstudies on ID.[9, 10]   Inadequate iron intake is a key factor in the development of irondeficiency and IDA. The Malaysian Adult Nutrition Survey (MANS) estimated iron intake*Corresponding author: Dr SP Loh;  Email: sploh@medic.upm.edu.myMalaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010SP Loh & GL Khor64of women at about 9.5mg/d, compared to 20mg/d recommended for women aged 19 to 50years.[11]This study was undertaken to assess the prevalence of ID, anaemia and IDA in womenaged 20-40 years in Kuala Lumpur suburbs and its association with iron intake.METHODSSubjectsWomen aged 18-40 years were recruited from universities and other work sites located inthe suburbs of Kuala Lumpur through convenient sampling.  The inclusion criteria includedbeing not pregnant or breastfeeding, not taking supplements regularly, not consumingalcohol habitually, not a habitual smoker and without a history of diabetes, hypertension,liver, heart or gastrointestinal problems.  Those who qualified, they were given a two-pageinformation sheet about the study. If they agree to participate, they were asked to sign aconsent form. The study protocol was reviewed and approved by the Medical ResearchEthics Committee of the Faculty of Medicine and Health Sciences, Universiti Putra Malaysia.Dietary IntakeDietary intake was determined using a single 24-hour recall and a semi-quantified foodfrequency questionnaire (FFQ).   The interviews were conducted by trained interviewers.The dietary data was analysed using Nutritionist Pro, version 2.5 (First Databank,California,USA).  The FFQ listed a total of 30 food items including  those high in iron andfrequently eaten by all ethnic groups.  For each food item, the following information wasrecorded: (a) frequency of consumption as number of times per day, per week, per month ornever and (b) number of portions usually consumed (slices, units or standard servings).Biochemical MeasurementsA total of 10 ml blood (non-fasting) was taken from each subject, for haemoglobin (Hb),haematocrit (hct), mean cell volume (MCV), and serum ferritin.  Hb, Hct and MCV weremeasured the same day with a haematology analyser (ABX micros-60, Horiba-ABX, France).Serum samples were stored at –20oC until sent to University of Otago, New Zealand for thedetermination of serum ferritin using an Axsym analyser and AxSYM Ferritin assay (AbbottLaboratories)Statistical AnalysisThe data were analysed using SPSS for Windows version 13.0 (SPSS, Chicago, IL, USA).Characteristics of the women were described using frequencies, percentages, means,standard deviations, median and percentiles (5-95th).  Anaemia was defined as a hemoglobinlevel less than 12g/dL, depleted iron store as serum ferritin less than 15μg/L, and irondeficiency anaemia as Hb less than 12g/dL, MCV less than 80fl and serum ferritin less than15μg/L.  Analysis of variance with a Duncan test for multiple comparisons was used todetermine differences among groups and a p value of less than 0.05 was considered toindicate statistical significance.Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010Iron Intake and Iron Deficiency Anaemia among Young Women in Kuala Lumpur 65RESULTSCompleted questionnaires and biochemical data were obtained from 388 (135 Malay, 130Chinese and 123 Indians) of the 399 women who were enrolled.  Table 1 summarises thecharacteristics of these 388 subjects who were included in all subsequent analyses.  Themedian age of the subjects was 23 years and 74.5% were in the 21-30 years age category.Two hundred and ninety-three (75.7%) of them were single and education attainment wasquite high (16 years or at about Form Five level).  This is due to the inclusion of a highproportion of university students as subjects, (60.3%). The working women were employedin a variety of positions including clerks, bank executives, factory operators, laboratoryTable 1.  General characteristics of the study sample (N=388)Malay Chinese Indian AllN= 135 N=  130 N= 123 N= 388Characteristics N (%)Age (yr)< 20 11 (8.2) 13 (10.0) 6 (4.9) 30 (7.7)21-30 96 (71.1) 108 (83.1) 85 (69.1) 289 (74.5)> 30 28 (20.7) 9  (6.9) 32 (26.0) 69 (17.8)Median (years) 25 22 24 235-95th percentiles (years) 20-38 20-33 20-39 20-38Marital statusSingle 83 (61.9) 124 (96.1) 86 (69.4) 293(75.7)Married 48 (35.8) 5 (3.9) 36 (29.0) 89 (23.0)Divorced/widowed 3 (2.2) - 2 (1.6) 5 (1.3)EducationPrimary 3 (2.2) - 7 (5.7) 10 (2.6)Secondary 35 (25.9) 3 (2.3) 24 9 (9.5) 62 (16.0)Form 6/matriculation 23 (17.0) 15 (11.6) 14 (11.4) 52 (13.4)College/University 74 (54.8) 111 (86.0) 78 (63.4) 263 (68.0)Median (yrs) 16 16 16 165-95th percentiles (yrs) 11-16 13-16 7-16 11-16OccupationWorking 77 (58.8) 12 (9.4) 37 (30.6) 126 (33.2)Students 50 (38.2) 116 (90.6) 75 (62.0) 241 (63.4)Housewives 4 (3.1) - 9(7.4) 13 (3.4)BMI (kg/m2)Mean + SD 24.1 ± 4.7a 21.2 ± 3.5b 22.3 ± 4.8c 22.6 ± 4.5Underweight (< 18.5) 10 (7.4) 29 (22.7) 24 (22.5) 63 (17.1)Normal (18.5-24.9) 81 (60.0) 88 (22.7) 63 (53.9) 232 (63.1)Overweight (25.0 –29.9) 27 (20.0) 6 (4.7) 7 (14.6) 40 (10.9)Obese (>30.0) 17 (12.6) 5 (3.9) 11 (9.0)  33 (8.9)Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010SP Loh & GL Khor66technologists and nurses.  The mean BMI was 22.6kg/m2 and the majority were in the normalcategory (63.1%).The mean intake and the corresponding 95% confidence intervals of energy, iron andvitamin C intakes are presented in Table 2.  Iron intake was similar in Malay and Indiansubjects but was significantly lower among the Chinese subjects.  Mean iron intake ofMalay and Indian subjects were 15.8 (13.9, 17.7)mg and 16.0 (14.0, 18.1)mg respectively,while that of the Chinese was 11.3 (9.8, 12.7)mg.  The main foods providing heme iron for allthree ethnic groups are chicken and eggs.  Pork is the additional heme iron source for theChinese.When the mean intake of iron of the subjects was compared to the MalaysianRecommended Nutrient Intake (RNI,) assuming 10% iron bioavailability,[12] it is seen that15.5% met the RNI level for iron.  About 76.5% of the subjects did not meet 2/3 of the RNI foriron.  In this respect, a higher percentage of Chinese subjects (88.3%) had inadequate ironintake compared to the Malays (68.1%) and Indians (74.4%).The levels of Hb, hematocrit, MCV and ferritin (mean + SD) of the subjects were 12.7 +1.5g/dl, 34.8 + 3.3%, 76.1 + 7.6fl and 29.3 + 27.8μg/L respectively (Table 3).  Overall, theIndian subjects had significantly lower Hb and serum ferritin levels compared to the Malayand Chinese subjects.  Depleted iron stores were found in 33% of the subjects with theIndians having the highest percentage (53.9%) followed by the Chinese (25.2%) and Malay(22.9%) (Table 4).  Overall prevalence of anaemia was 20.9%, while the combination ofanaemia and depleted iron stores was found in 11.6 % of the subjects.  The majority of thewomen with depleted iron stores (64.1%) were not anaemic.  Severe anaemia (<7g/dL) wasfound in only three subjects; thus most of the women could be considered as having mildTable 2. Mean energy and nutrient intake of subjects (N= 388)Variable RNI Mean (95 % CI)Malay Chinese Indian AllN= 135 N=  130 N= 123 N= 388Energy (kcal) 2000 1443 1251 1505 1402(1355, 1532)a (1177, 1324)b (1404, 1607)a (1350, 1453)Protein (g) 55 57 50 57 55(53, 61)a (46, 54)b (52, 62)a (52, 57)Fat (g) 46-70 46 42 46 45(42, 50)a (36, 48)a (41, 51)a (42, 48)Iron (mg) 20-29 15.8 11.3 16.0 14.4(13.9, 17.7)a (9.8, 12.7)b (14.0, 18.1)a (13.4, 15.5)Vitamin C 70 60 53 56 56(48, 73)a (42, 63)a (45, 66)a (50, 63)ANOVA post-hoc test (Duncan): mean values with different superscripts are significantly different atP<0.05 levelMalaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010Iron Intake and Iron Deficiency Anaemia among Young Women in Kuala Lumpur 67Table 3. Iron status of subjectsMalay Chinese Indian AllN= 135 N=  130 N= 123 N= 388Hemoglobin (g/dL) 12.8 + 1.6a 12.8 + 1.2a 12.4 + 1.6b 12.7 + 1.5Hematocrit (%) 35.1 + 2.9a 34.4 + 3.0a 34.7 + 3.9a 34.8 + 3.3Mean cell volume (fl) 76.4 + 6.2a 76.5 + 7.5a 75.1 + 8.9a 76.1 + 7.6Ferritin (μg/L) 35.0 + 31.9a 32.4 + 27.7a 20.1 + 20.2b 29.3 + 27.8ANOVA post hoc test (Duncan): mean values with different superscript are significantly different at P<0.05 levelTable 4. Prevalence of anaemia, depleted iron stores and IDAClassification based on Malay Chinese Indian AllWHO (2001) [15] N= 135 N=  130 N= 123 N= 388Anaemia (Hb <12 g/dL) 16.4 20.6 26.4 20.9Depleted iron store 22.9 25.2 53.9 33.0(ferritin <15 μg/L)Iron deficiency anaemia 4.3 9.9 18.0 10.3(Hb < 12 g/dL + ferritin< 15 μg/L + MCV < 80fl)(10-11.9 g/dL) to moderate levels (7-9.9 g/dL) of anaemia.  Based on the WHO definition,[13]the prevalence of IDA was 10.3% with the Indians having the highest percentage (18.0%)followed by the Chinese (9.9%) and Malays (4.3%) (Figure 1).DISCUSSIONThe overall prevalence of anaemia in this study was 20.9%, while iron deficiency anaemiawas at 10.3%, indicating that about half of the anaemia was due to iron deficiency.  Othercauses of anaemia in young women include heavy menstruation for longer than five days,abnormal uterine bleeding, (such as from fibroids)[14] and pregnancy.[15]The prevalence of anaemia found in young non-pregnant women (20.9%) appearshigher than the WHO estimate for non-pregnant women in Thailand at 18%.[16]  However,there is a lower prevalence of iron deficiency anaemia compared to young adolescent girlsfrom Indonesia (21.8%)[17]. Similarly, women of reproductive age in northwest Vietnamreported a higher prevalence of anaemia (37.5%).[18]Serum ferritin is normally used as a marker of iron stores.  The prevalence of irondepletion in women studied was 33%.  Low iron stores without anaemia, is a commonlyobserved situation, especially in menstruating women.  One reason for this is that the usualMalaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010SP Loh & GL Khor68diets in the population may not meet the high iron requirements of the menstruating women.Some other factors, such as type of contraception in women, blood donation or minorpathological blood loss (hemorrhoids, gynecological bleeding), may increase the difficultyof covering iron needs. Moreover, women, especially those consuming low-energy diets,vegetarians and vegans are at particularly high risk of iron deficiency.[19]In developing countries including Malaysia, dietary iron is derived mainly from meatand legumes.  Overall, the intake of iron in this study was slightly higher than thosereported by the MANS study,[11] and was similar to levels reported in adults in Manila,[20]and Hong Kong.[21]  The Indian subjects had the highest prevalence of anaemia and IDA,despite having a higher mean daily iron intake (16.0mg/d) than that of the Chinese (11.3 mg/d) and Malay (15.8 mg/d).  This may be due to low bioavailability of iron from dhal and otherlegumes that are frequently consumed by Indians generally.  Iron from these vegetablesources has less than 5% bioavailability due to the presence of inhibitors of iron absorptionincluding phytate.[22]  Food items taken that could enhance iron absorption in this sample ofsubjects are mainly cabbage and orange owing to their vitamin C content.CONCLUSIONSThe prevalence of anaemia and IDA among urban Malaysian women were 20.9% and 10.3%,respectively, and marked differences were found among the ethnic groups.  Interventionstrategies for the reduction of anaemia and iron deficiency should be sensitive to culturalpractices including food preferences and preparation.  Pre-pregnancy evaluation providesimportant information for effective intervention strategies and may play a crucial role inpreventing development of IDA during pregnancy.ACKNOWLEDGEMENTSWe convey our appreciation to Dr G. Duraisamy and the staff of the Clinical LaboratorySciences Department (Haematology Unit) in Universiti Putra Malaysia, and to Dr TJ GreenMild to moderate irondeficiency (withoutanaemia) 33.0%Anaemia 20.9%Iron deficiencyanaemia 10.3 %Figure 1. Prevalence of anaemia, iron deficiency and IDA in Malaysian womenMalaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010Iron Intake and Iron Deficiency Anaemia among Young Women in Kuala Lumpur 69and Prof. CM Skeaff , Department of Nutrition in University of Otago for their technicalsupport.  Fonterra Brands, New Zealand provided funding for the study.REFERENCES[1] World Health Organization.  Malnutrition, the Global Picture.  Geneva:WHO, 2000.[2]  Aleen LH, Gillespie SR.What works?  A review of the efficacy and effectiveness of nutritionintervention.   ACC/SCN: Geneva in collaboration with the Asian Development Bank, Manila,2001.[3] Walter T. Effect of iron-deficiency anaemia on cognitive skills and neuromaturation in infancyand childhood. Food Nutr Bull 2003; 24(4 Suppl): S104–10.[4] Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T.  Long-lasting neural andbehavioral effects of iron deficiency in infancy. Nutr Rev 2006; 64(5 Pt 2): S34–43.[5] Bruner AB, Joffe A, Duggan AK, Casella JF, Brandt J. Randomised study of cognitive effectsof iron supplementation in non-anaemic iron-deficient adolescent girls. Lancet 1996; 348(9033):992–6.[6] Scholl TO. Iron status during pregnancy: setting the stage for mother and infant. Am J ClinNutr 2005; 81(5): 1218S–1222S.[7] Golub MS, Hogrefe CE, Tarantal AF, Germann SL, Beard JL, Georgieff MK, Calatroni A,Lozoff B. Diet-induced iron deficiency anaemia and pregnancy outcome in rhesus monkeys.Am J Clin Nutr 2006; 83(3): 647–56.[8] Milman N. Prepartum anaemia: prevention and treatment. Ann Hemato 2008; 87(12): 949–59.[9] Hassan R, Abdullah WZ,  Nik Hussain NH. Anaemia and iron status of Malay women attendingan antenatal clinic in Kubang Kerian, Kelantan, Malaysia. Southeast Asian J Trop Med PublicHealth 2005; 36(5):1304–7.[10] Sagin DD, Ismail G, Mohamad M, Pang EK, Sya OT.  Anaemia in remote interior communitiesin Sarawak, Malaysia. Southeast Asian J Trop Med Public Health 2002; 33(2): 373–7.[11] Kandiah M, Mohd Shariff Z, Mohd Yusof S, Aris T, Mohd Din SH,  Din SR, Mohd Yusop KZ,Saihun MH, Haron N. Energy and Nutrient Intakes of Malaysian Adults: Findings from TheMalaysian Adult Nutrition Survey (MANS).  Mal J Nutr 2008; 14 (1): 1–24.[12] National Coordinating Committee on Food and Nutrition (NCCFN), Ministry of HealthMalaysia. Recommended Nutrient Intakes for Malaysia. Putrajaya, Ministry of HealthMalaysia, 2005.[13] WHO.  Iron deficiency anaemia: Assessment, Prevention and Control. A guide for programmemanagers. World Health Organization; 2001.Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010SP Loh & GL Khor70[14] Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best practice & research. ClinObstet & Gynaecol 2008; 22(4): 615–626.[15] American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 95: anaemiain pregnancy. Obstet Gynecol 2008; 112(1): 201–7.[16] WHO. Nutrition in South-East Asia.  World Health Organization,  Regional Office for South-East Asia: New Delhi, 2000.[17] Kurniawan YA, Muslimatun S, Achadi EL, Sastroamidjojo S. Anaemia and iron deficiencyanaemia among young adolescent girls from the peri urban coastal area of Indonesia. Asia Pac JClin Nutr 2006; 15(3): 350–6.[18] Pasricha SR, Caruana SR, Phuc TQ, Casey GJ, Jolley D, Kingsland S, Tien NT, MacGregor L,Montresor A, Biggs BA. Anaemia, iron deficiency, meat consumption, and hookworm infectionin women of reproductive age in northwest Vietnam. Am J Trop Med Hyg 2008; 78(3): 375–81.[19] Hallberg L, Hulthen L, Garby L. Iron stores and haemoglobin iron deficits in menstruatingwomen. Calculations based on variations in iron requirements and bioavailability of dietaryiron. Eur J Clin Nutr (2000); 54(8): 650–657.[20] Nakatsuka H, Zhang ZW, Agetano MG, Subida RD, Inouguchi N, Watanabe T, Shimbo S,Higashikawa K, Ikeda M.  Total food duplicate study on nutrient intake of working women inManila, the Philippines. Tohoku J Exp Med 1998; 184(3): 189–205.[21] Woo J, Leung SSF, Ho SC, Lam TH, Janus ED.  Dietary intake and practices in the Hong KongChinese population. J Epidemiol Community Health 1998; 52: 631–637.[22] Hurrell RF. Influence of vegetable protein sources on trace element and mineral bioavailability.J Nutr 2003; 133(9):2973S–7S.

Iron intake and iron deficiency anaemia among young women in

Kuala Lumpur

http://psasir.upm.edu.my/7787/1/Iron_in_Women63-70%28edSP%29.pdf

Iron intake and iron deficiency anaemia among young women in Kuala Lumpur

Abstract

Similar works

Full text

Available Versions

Universiti Putra Malaysia Institutional Repository