An-Najah National University Faculty of Graduate Studies Prevalence of Iron Deficiency Anemia among School Children in Salfeet District By Mohammad Mahmoud Mohammad Odeh Supervisor Dr. Nael S. Abu-Hasan Co- Supervisor Dr. Riad Amer Submitted in Partial Fulfillment for the Requirements for the Degree of Master in Public Health, Faculty of Graduate Studies, at An-Najah National University, Nablus, Palestine. 2006 III Dedication To My Beloved Wife, Parents for their Patience and Encouragements with Love and Respect IV Acknowledgement I would like to express my deep thanks for my supervisors Dr. Nael S. Abu-Hasan and Dr. Riad A. Amar for the valuable discussions, efforts, encouragements and their continuous support throughout this study. Thanks to Mr. Yaseen Afaneh for his kind help and assistance in statistical analysis. Thanks are also due to the Palestinian Ministry of Education, Directorate of Education and School Headmasters at Salfeet district for their help in sample collection. Thanks to administrative and lab. technicians at Al-Watany Hospital for their kind help and assistance in blood analysis. Last but not least thanks are due to my beloved wife, parents and family for their continuous support during my years of study. V List of Contents Contents page Dedication III Acknowledgment Iv List of Contents V List of Tables VI Abstract VII CHAPTER ONE: INTRODUCTION 1.1 General Background 2 1.2 Definition 3 1.3 Pathophysiology 3 1.4 Iron needs during infancy and childhood 6 1.5 Causes of iron deficiency anemia 8 1.6 Symptoms of iron deficiency anemia 9 1.7 Diagnosis of iron deficiency anemia 10 1.8 Treatment 12 1.9 Patient Education 13 1.10 Complications 13 1.11 Prevention 14 1.12 The prevalence and distribution of iron deficiency 15 worldwide 1.13 Iron deficiency anemia in Palestine 16 1.14 Objectives of the study 17 CHAPTER TWO: METHODOLOGY 2.1 Study sample 19 2.2 Tools of study 20 2.2.1 Questionnaire 20 2.2.2 Blood tests 20 2.3 Procedure 20 2.4 Data analysis 21 CHAPTER THREE: RESULTS AND DISCUSSION 22 3.1 Prevalence of ID and iron deficiency anemia 23 3.2 Knowledge, awareness and practices of study 29 population towards iron deficiency 3.3 Healthy practices and iron deficiency 35 3.4 Consequences of iron deficiency 38 3.5 Recommendations and concluding remarks 42 References 43 Appendices 51 Arabic abstract ب VI List of Tables Table Page Table 1.1 The normal values for the age-matched red cell 11 indexes, and serum iron Table 1.2 Estimated percentage of anemia prevalence (1990- 15 1995) based on blood hemoglobin concentration Table 1.3 Estimated prevalence of anemia (1990-1995), WHO 16 regions based on blood hemoglobin concentration Table 2.1 Distribution of the study sample 19 Table 2.2 Cutoff values for iron deficiency and anemia 20 Table 3.1 Prevalence of iron deficiency by demographic 29 patient characteristics Table 3.2 Prevalence of iron deficiency according to family 34 awareness regarding diet maintaining iron levels Table 3.3 The prevalence of iron deficiency related to the 38 practice (health profiles) of the study population Table 3.4 Prevalence of iron deficiency according to 41 consequences of the disease VII Prevalence of Iron Deficiency Anemia among School Children in Salfeet District By Mohammad Mahmoud Mohammad Odeh Supervisor Dr. Nael S. Abu-Hasan Abstract A cross-sectional study conducted in the second semester of the academic year 2005 to investigate the prevalence of iron deficiency anemia in school children aged 6 to 18 years, who live in the district of Salfeet in the West Bank area of Palestine. The study sample consisted of 144(49.7 %) male students, and 146 (50.3 %) female students. Complete blood count (CBC) was performed and blood samples with main corpuscular volume (MCV) value less than 80um³(FL) were subjected to serum iron test. The prevalence of iron deficiency was 26.7% (12.7% with anemia, and 14% without anemia). The prevalence of iron deficiency among females was 30.5%, and among males was (21.6%). Iron deficiency was apparent in all studied age groups. The prevalence of 32.4% was observed among the age group 6- 8 years, 35.3% among age group 9-11 years, 25.9% among 12-14 years and 12.1% among 15-18 years old. Differences in prevalence rates were statistically significant (P= 0.01 at α = 0.05). According to place of residency, there was statistically significant difference between the overall prevalence of iron deficiency among children living in villages compared to children living in the city (22.8% versus 32.6% respectively, P < 0.01). There was no clear link between family size and iron deficiency. With respect to prevalence of iron deficiency and family income, no significant difference was observed (24.9% low income; 28.1% with medium and 30.2% with high income). In general, improper daily healthy practices and poor knowledge regarding VIII iron rich nutrients and its absorption found. Previous history of other diseases seems to contribute to the highly observed prevelance rate of IDA. To effectively face these deficiencies it is necessary to think about the possibilities and cost effectiveness of fortifying foodstuffs (floor, salt, milk) and it is essential to carry out nutritional education activities to improve children and parents awareness and knowledge regarding iron deficiency anemia and its consequence. Chapter One Introduction 2 1.1 General background Iron deficiency is the most prevalent and common micronutrient deficiency in the developing world today (Tatala et al., 1998; Asobayire et al., 2001; Abalkhail and Shawky, 2002; Hashizume et al., 2003). The public health effects of iron deficiency include anemia, decreased intellectual and work performance as well as functional alterations of the small bowel (Oski, 1993). Beside other vulnerable age groups, such as infancy and early childhood, adolescence is placed at a high risk level for developing iron deficiency, due to a combination of menstrual iron losses in girls and a rapid physical growth, especially in boys (Fomon et al., 2003). Poor diet quality and low dietary iron bioavailability are the principal factors that contribute to the increased incidence of iron deficiency (Tatala et al., 1998). The bioavailability of haem iron, present in animal products, is high with absorption rates of 20−30%, whereas the bioavailability of nonhaem iron is determined by the presence of enhancing or inhibiting factors (Hurrell, 1997). The main enhancers of nonhaem iron absorption are meat (haem iron) and vitamin C (Cook & Reddy, 2001). Inhibitors include phytate (nuts, bran and oat products, whole-wheat and brown flour), polyphenols (tea, coffee, cocoa, some spices and vegetables), calcium (milk products) and Phosphorous (Reddy et al., 2000). In developing countries, low standards of living, low socio-economic conditions, restricted access to food and lack of knowledge for good dietary practices and personal hygiene contribute even more to a high occurrence of iron deficiency and hence anemia (Hall et al., 2001; Islam et al., 2001; Soekarjo et al., 2001). Intestinal parasitic infection, due to poor hygienic