Prevalence and factors associated with anemia in adults in the UAE

Introduction

As per the World Health Organization (WHO), “anemia is defined as hemoglobin (Hb) levels <12.0 g dL⁻¹ in women and <13.0 g dL⁻¹ in men”.¹ Weakness, fatigue, dizziness, and shortness of breath - common symptoms of anemia. The primary nutritional deficiency contributing to anemia is iron deficiency.² A patient may be symptomatic depending on underlying etiology or concurrent co-morbidities. Reduced RBC synthesis, increased hemolysis (the breakdown of red blood cells), or blood loss could cause a drop in hemoglobin levels. A systematic review assessing the global prevalence of anemia found mild anemia ranges from 53.8% to 54.4%, moderate anemia ranges from 42.2% to 42.7% and severe anemia ranges from 3.3% to 3.5%.³ In 2021, 1.92 billion individuals worldwide were anemic. As per WHO, the prevalence of anemia in 15–49-year-old women was 24.3%.⁴

Rates of incidence for anemic men increased monotonically with age, but in adult women, it bimodally peaked within the age group 40-49 years and 80-85 years. The prevalence was 29.6% in reproductive-age non-pregnant women and 36.5% in pregnant women.⁴ Western regions are least impacted, but South Asia and Sub-Saharan Africa are most affected (36.5% in East Africa).⁵ In Ethiopia (among the Sub-Saharan nations), anemia is a significant problem. Anemia is highly prevalent in both men and women dwelling in urban areas of Cameroon, Africa. In a Pakistan study, mild anemia was found among 46-60 year old’s while moderate anemia was present in 10-30 year olds.⁶ A study in India found that nine out of 93 men had anemia with a hemoglobin level <10 mg dl⁻¹. According to a South Australian study, 23% of expectant mothers took their Iron and Folic acid supplements as prescribed. In Europe, the prevalence of anemia in adults aged 16 to 50 is from 4% to 33%. A study on European adults found that 11% of the iron-deficient population had anemia. 9.1% of iron-deficient men had anemia, while 12.1% of iron-deficient women had anemia. 23.2% of adults in Saudi Arabia present with iron deficiency, with younger persons having greater frequency than older adults.⁷ In Saudi Arabia, the reported prevalence of iron deficiency anemia ranges from 10% to 60%. The prevalence of anemia in women ranges from 27% to 69.6%, with 34.4% in Morocco, 28.5% in Egypt, 32.5% in Libya, and 30.7% in Sudan.⁸

Age, sex, pregnancy status, smoking habits and altitude above sea level, along with contagious diseases like tuberculosis, parasitic infections, malaria, HIV, and other hemoglobinopathies determine hemoglobin levels.^2,9 Studies reported that red meat, eggs, green leafy vegetables, dates, beetroot juice, pomegranate, lentils, jaggery, dates, beef liver, and sardine are protective factors of anemia.^2,10–19 A study from Iran indicated that consuming dates increases hematocrit, hemoglobin and serum ferritin levels across every age group. Through studies conducted in Pondicherry and Saudi Arabia, it was proved significantly that Hb levels, serum iron, and ferritin improved with beetroot juice and jaggery, and a decrease in the levels of Total Iron Binding Capacity (TIBC) and transferrin was observed regardless of the age group.¹⁸ Pomegranate helps in increasing the absorption and assimilation of iron. A study concluded that 100g of pomegranate arils for 30 days increased the hemoglobin concentration in adolescent girls.¹⁹ A study from India reported that smokers had a significant increase in their hemoglobin, RBC count, MCHC, MCV, and WBC count compared to smokers without anemia.²⁰ Insufficient intake of protein sources, such as eggs, legumes, and red meat like mutton/beef, caused a low hemoglobin level (below 12 g dL⁻¹) and influenced serum ferritin levels in the blood.¹⁴ Studies observed that exercise, smoking and alcohol are protective factors,^6,20,21 whereas other studies reported them as risk factors.²² Poverty, low educational and socioeconomic status, scarce water resources and toilet facilities are important lifestyle factors contributing to anemia. Anemia can worsen vascular ischemia in vulnerable patients and increase mortality rates.²³ This study aimed to determine the prevalence of anemia and the associated factors among adults residing in the UAE. The study also aimed to assess the knowledge about anemia among the study population.

Methods

This was a cross-sectional study conducted from July 2023 to February 2024, targeting adults residing in the UAE. We followed STROBE guidelines as given on https://www.equator-network.org/. Participants of any nationality with the ability to read, write, and understand English and males and females of 18-50 years were included. Adult subjects with severe chronic diseases, individuals unable to comprehend the questionnaire, those deemed incompetent, and those who did not provide consent were excluded. The minimum sample size calculated was 341. Three hundred ninety-five adults participated in the research. The questionnaire included domains like sociodemographic characteristics, history of anemia, diet and lifestyle, knowledge about anemia, and reproductive health questions for females. The questionnaire was sent for validation to ensure it was structured. After validation, a pilot study was conducted. Before conducting the study, approval was taken from the University Institutional Review Board (No. IRB-COM-STD-100-May-2023). We followed Declaration of Helsinki. Informed consent was obtained from each participant before the commencement of the research. We maintained confidentiality, anonymity, and privacy of the participant's data. After finalizing the questionnaire, we created a Google form with a consent form and collected data through a QR code. Once all the required sample size responses had been collated, data was entered into Microsoft Excel and transferred to SPSS for statistical analysis. Descriptive statistics was used to summarize the data and the Chi-Square test was used to determine the association. Simple and multiple binary logistic regression was used to assess the degree of association. This was a cross sectional study so possibility of bias such as recall bias and non response bias along with social desirability.

Results

Among the 395 participants, 220 (55.7%) were females and 175 (44.3%) males. Among the participants, 143 (36.2%) were below 20 years old, while only 72 fell within the 30-40 age group. The majority of participants, 165 (41.8%), had received education up to the university level, and 50.6% were employed. The study included various professions such as Nurses, Teachers, Construction workers, Labourers, Engineers, Doctors, Technicians, Hotel employees, Accountants, and Managers. Of the participants, 299 (75.7%) were from the Southeast Asian region, comprising the majority, and 57.7% were unmarried. In terms of residence, 41.8% were from Dubai, 24.6% from Umm Al Quwain, and the rest were evenly distributed across all the emirates of the UAE. 18.5% of the participants reported having a previous positive history of anemia; 8.9% were currently diagnosed with anemia, and 10.6% reported taking iron supplements. Additionally, 16.2% of the participants had a family history of anemia.

In the study, 114 participants reported purchasing iron-fortified foods. The participants' dietary habits revealed that a majority consumed green leafy vegetables, accounting for 93.7%, while approximately 78.5% included dates in their diet. Beetroot was consumed by around 59.5% of the participants, and pomegranate intake was reported by about 67.3%. Red meat was part of the diet for approximately 63.2% of the participants, while 50.6% included jaggery/molasses. Eggs were consumed by a substantial 86.8% of the participants, and lentils were part of the diet for around 83.2%. Similarly, beans were consumed by approximately 83.8%, while beef liver was included by about 25.8% of the participants. Chickpeas were part of the diet for around 74.4%, and sardines were consumed by approximately 35.9%. Furthermore, chicken was a dietary choice for about 85.1%, and tea was consumed by approximately 84.5% of the participants.

Approximately 33 participants (8.4%) reported smoking, while around 62 participants (15.7%) indicated alcohol consumption. A significant portion of the participants reported regular exercise, totaling approximately 244 (61.8%). Among the 244 adults who exercised, 95.9% preferred walking, whereas only 29.9% reported swimming as part of their exercise routine.

Discussion

Prevalence: The present study shows 3.4% of male and 13.2% of female adults had anemia. A study among university students revealed that 18.1% of females suffered from anemia.²⁴ From 2007-2019, the prevalence of anemia among women in UAE between 15-49 years was noted to be 24.3%.²⁵ Our study agrees with another study, which showed that males across all ages have a reduced prevalence of anemia compared to females. In 2021, 17.5% of males had anemia, while 31.2% women had anemia.²⁶

The values reported in our study are much lower, possibly due to improvement in adults' educational and socioeconomic status and regular usage of iron supplements. Since the rates of thalassemia, hemoglobinopathies, and dietary inadequacies are elevated, the prevalence of anemia among individuals from the Middle East is significantly greater than in Western societies.²³

Sociodemographic factors associated: A statistically significant association between gender and anemia reported from the present study. As per our study, the chance of anemia in females is 3.2 times that of males. Females are more likely to suffer from anemia due to stress, multiple pregnancies, menstrual blood loss and negligence of regular health checkups.²⁷

Dietary factors associated: A study found that those who consumed fewer or no green leafy vegetables were roughly twice as likely to be anemic as those who did not.²⁸ In our study, no significant association was found.¹⁷ Sukkari Dates can raise blood iron levels, particularly in menstruating women and prevent anemia.¹⁰ Our study found a significant association between the consumption of dates and anemia. By raising Hb levels, beetroot juice can treat anemia, as shown by a study of giving beetroot juice to adults. Our study found no significant association between the consumption of beetroot and anemia. A study in Greece found that pomegranate juice supplementation can increase RBC count, hemoglobin concentration and hematocrit in healthy individuals by promoting RBC formation and erythropoiesis or in preventing RBC degradation.¹⁵ Our study found no significant association between the consumption of pomegranate and anemia. A study found a link between animal meat consumption and iron status and that meat-based heme iron absorbs far better (up to 35%) than plant-based non-heme iron (2-10%).²⁹ Our study found no significant association between the consumption of red meat and anemia. A study from Columbia reported that red meat and eggs were determined to positively influence serum ferritin levels in the blood.¹⁴ No association was found in our study between the consumption of eggs and anemia. Eating jaggery and raisins could aid in treating anemia and improve iron absorption.¹⁶ Our study found a significant association between the consumption of jaggery/molasses and anemia. 5.8% of participants who consumed jaggery/molasses had anemia, while 12.3% of participants who did not consume jaggery/molasses had anemia. Consumption of chicken, fresh fish, and dried fish was positively linked with knowledge of iron sources and iron-rich meals. Consumption of chicken and dry fish lowered the risk of anemia development.³⁰ Lentils are frequently considered a nutrient-dense food that is high in iron.³¹ Our study found no significant association between the consumption of lentils and anemia. In Brazil, fortified wheat flour was identified as the main food contributor to dietary iron, with contributions exceeding those of traditional food sources such as red meat and beans, frequently consumed in the Brazilian dietary regimen. Chickpeas have been studied as a potential source of iron fortification.²⁶ Our study found no significant association between the consumption of chickpeas and anemia.

A study found that beef liver had the maximum total iron content among all beef viscera.³² This was in agreement with our study, which found that 1.8% of adults in UAE who eat beef liver currently have anaemia, while 11.7% of adults who do not consume beef liver suffer from anemia.

Oil-rich sardine improves iron absorption. Our study found a significant association between the consumption of sardine and anemia. 2.1% of adults in UAE who eat sardines have anemia, while 12.8% of adults who do not currently consume sardines suffer from anemia. Our study also found that adults who incorporate sardines into their diet are 3.8 times less likely to suffer from anemia. A study shows the inhibitory effect of iron absorption inhibitors found in tea, coffee, and cocoa.³³ Our study found no significant association between the consumption of tea and anemia.

Lifestyle factors associated: Hemoglobin levels were substantially higher in smokers than non-smokers, regardless of gender, whereas there was no significant difference in hematocrit levels between smokers and non-smokers.³⁴ Male smokers, on the other hand, had significantly higher hematocrit values than female smokers. Our study found no significant association between anemia and smoking. Consumption of up to two alcoholic drinks per day appears to be related to a lower risk of iron deficiency and anemia.³⁵ In our study, we found no association between anemia and alcohol consumption. While comparing resistance and aerobic exercises, resistance exercises were found to elevate exercise-induced hepcidin to a greater extent, thus causing iron deficiency anemia.¹¹ Our study did not find an association between anemia and exercise.

Conclusion

This study observed that 18.4% of adults in the UAE had experienced anemia at some point. Furthermore, the current prevalence of anemia among adults in the UAE stands at 8.9%. Females exhibit a higher prevalence of anemia than males, with 13.2% of females currently affected compared to 3.4% of males. The age group above 40 years demonstrated the highest prevalence of anemia at 13.4%, while the age group 30-40 years had the lowest prevalence at 4.2%.

Significant associations observed between gender, consumption of dates, jaggery/molasses, beef liver, and sardines, and anemia. No significant associations were found between anemia and the consumption of green leafy vegetables, beetroot juice, pomegranate juice, red meat, eggs, lentils, beans, chickpeas, chicken, and tea. Lifestyle factors such as smoking, alcohol consumption, and exercise. This study also reveals that females with 3.2 times higher likelihood of anaemia, and those who are not consuming sardine the likelihood of anaemia is 3.8 times higher.

Ethics declarations

This study was approved by the Institutional Review Board of Gulf Medical University (IRB-COM-STD-100-May-2023) on 29^th May 2023. Signed consent form was received from all participants. This research was conducted in accordance with the Declaration of Helsinki.

Consent for publication

All authors consent to the publication of the paper. We followed STROBE checklist to complete this manuscript.

Authors’ contributions

P.P – concept development, data collection, data analysis, manuscript preparation.

J.S – concept development, data collection, data analysis, manuscript preparation.

M.D – concept development, data collection, data analysis, manuscript preparation.

M.R – concept development, data collection, manuscript preparation.

J.D – supervising the work.

All the authors read, revised, and approved the final manuscript.