Obesity and iron-deficiency anemia in women of reproductive age in northern Iran
Hajar Adib Rad1, Sayed Ali Asghar Sefidgar2, Ahmad Tamadoni3, Sadegh Sedaghat4, Fatemeh Bakouei1, Ali Bijani5, Shabnam Omidvar1
1 Infertility and Health Reproductive Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
2 Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
3 Non-Communicable Pediatric Disease Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
4 Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
5 Social Determinants of Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
|Date of Submission||13-Nov-2018|
|Date of Acceptance||12-Feb-2019|
|Date of Web Publication||27-Jun-2019|
Dr. Shabnam Omidvar
Infertility and Health Reproductive Research Center, Health Research Institute, Babol University of Medical Sciences, Babol
Source of Support: None, Conflict of Interest: None
BACKGROUND: Obesity and iron deficiency (ID) are two forms of the most usual nutritional disorders worldwide. Some studies have discovered a correlation between ID and obesity although more investigation is required. This study was aimed to determine the association between obesity and ID anemia (IDA) in Iranian childbearing age women.
MATERIALS AND METHODS: This cross-sectional study was done on 256 women of reproductive age in northern Iran. The anthropometric measurements including height and weight were measured, and body mass index (BMI) was calculated. Low blood index of the hemoglobin (Hb), mean cell volume (MCV), and mean corpuscular hemoglobin (MCH) were evaluated with ferritin, serum iron, and total iron-binding capacity. Baseline data were expressed as means ± standard deviations. Chi-square test was applied to compare the categorical variable. Differences between the two groups were evaluated with independent samples t-test. A value of P < 0.05 was considered as statistically significant.
RESULTS: Obesity was in urban women higher than rural women (55.1% vs. 44.9%), and this difference was significant (P < 0.021). There was found no association between hematological characteristics and BMI. The data showed that only 13.4% of obese women and 17.1% of the women with normal weight had IDA (odds ratio = 0.75; 95% confidence interval: 0.39–1.49, P > 0.05).
CONCLUSIONS: According to the results of this study, it seems that the relationship between obesity and IDA is controversial. Hence, further studies are needed to be done.
Keywords: Body mass index, iron-deficiency anemia, obesity, reproductive age
|How to cite this article:|
Adib Rad H, Sefidgar SA, Tamadoni A, Sedaghat S, Bakouei F, Bijani A, Omidvar S. Obesity and iron-deficiency anemia in women of reproductive age in northern Iran. J Edu Health Promot 2019;8:115
|How to cite this URL:|
Adib Rad H, Sefidgar SA, Tamadoni A, Sedaghat S, Bakouei F, Bijani A, Omidvar S. Obesity and iron-deficiency anemia in women of reproductive age in northern Iran. J Edu Health Promot [serial online] 2019 [cited 2019 Oct 16];8:115. Available from: http://www.jehp.net/text.asp?2019/8/1/115/261566
| Introduction|| |
Globally, obesity has approximately doubled over the last three decades. While obesity has become a socioeconomic load in industrialized countries over the last centenary, the prevalence is currently also increasing in developing countries with the expanse of energy-dense food compounds and a low-level lifestyle.
The universal incidence of obesity has increased over the past 50 years. Recently, more than 1 billion people are thought to have BMIof more than 30 kg/m2, and the number is expected to increase over the next 30 years. Among micronutrients, iron plays a main role not only for Hb synthesis alone but also for oxidative metabolism and energy product. ID and IDAhave been shown to underlie serious public health issues; decreased iron reserves affect cognitive development and behavior, energy metabolism, immune status, bone health, and work capacity in humans.
Obesity and ID are two forms of the most usual nutritional disorders worldwide. The prevalence of ID and IDA is highest in the developing country; however, the scarce iron situation continues to exist in the developed countries.
Epidemiological evaluation has shown that the prevalence of anemia excesses with age. Both obesity and ID are independently major disease burdens. Studies have described an association between ID and obesity in children and adults., Low level of serum iron was observed with weight gain and increasing BMI in the decades ago that confirmed in the subsequent evaluations. Both ID and obesity are worldwide epidemics affecting billions with regional variation. Globally, childbearing age women are at risk of IDA, which causes important morbidity and mortality., This may be due to an increase in their parity that reduces the supply of iron in these women.
ID and anemia may lead to exhaustion and therewith to an additional decline in physical activity, further irritating weight gain. It has become obvious that ID and obesity do not just represent the coincidence of two frequent status but are molecularly linked and mutually affect each other. The most important complication of obesity includes Type 2 diabetes, cardiovascular diseases, and an increased rate of various cancers.,
The relationship between obesity and anemia should be explored further because they affect the health outcomes. The current study aimed to determine the association between obesity and ID anemia in women of reproductive age in Babol, Iran.
| Materials and Methods|| |
Participants and data collection
This cross-sectional study was conducted on 256 women of childbearing age (115 normal weight and 141 obese) in urban and rural areas of Babol in northern Iran. Nonpregnant and nonlactating women of reproductive age with one and two parity were interviewed by questionnaire. Demographic characteristics, medical history, and reproductive information were collected. Inclusion criteria included women between 20 and 35 years of age, those willing to be examined, and not using any medication during the study. Exclusion criteria included women more than the age of 35 years and under 20 years, unwillingness to participate in the study, known risk of anemia other than ID anemia, chronic infectious and noninfectious diseases, use of iron in the past 3 months and at present, the use of methods of contraception such as DMPA, IUD, OCP, and other hormonal methods.
Measurements and laboratory data
The anthropometric measurements including height and weight were measured, and BMI was calculated. Women' weight was measured with light clothes, without shoes (by Seca Sensa 804, Hamburg, Germany), and the height was measured (by Seca 206, Hamburg, Germany). BMI (kg/m2) was calculated for all persons by dividing weight in kilograms by the square of their height. Women were classified as normal weight (BMI ≥18.5–<25 kg/m2) and obese (BMI ≥30 kg/m2), according to the WHO criteria.
Five milliliters of 8 h-fasting venous blood samples were taken from all participants during follicular phases of the menstrual cycle. Blood samples were evaluated for red blood cells (RBC), Hb, hematocrit (Hct), MCV, and MCH.
Hb concentration was measured in the field on ethylenediaminetetraacetic acid. Serum iron concentration and total iron-binding capacity (TIBC) were determined spectrophotometrically with an RA-1000-automated system (Technicon, Tarrytown, NY, USA) using a colorimetric method (Fe SYS 1 and test-combination iron-binding capacity; Boehringer Mannheim). Furthermore, additional tests were done to confirm the IDA in two groups included ferritin, serum iron and TIBC.
The serum was evaluated for ferritin, TIBC, and iron if the blood samples were with Hb <12 g/dL, MCV <80 fL, and MCH <27 pg. The serum iron <50 μg/dL, ferritin <15 ng/mL, and TIBC >400 μg/dL were considered as ID anemia.
Test results were considered as minor thalassemia if they were included normal or high-level Hb and serum iron, low-level MCV and MCH as well as normal-level serum ferritin and TIBC. Therefore, people with minor thalassemia excluded from the study.
Furthermore, Hb >15 was considered as polycythemia and excluded from the study. The institutional ethical review board of Babol University of Medical Sciences, Iran, approved the research protocol (ID: MUBABOL.REC.1833). The inform consent forms were signed by all the participants before the study on the Declaration of Helsinki.
Statistical analysis was performed using Statistical Package for the Social Science (SPSS) 18.0 software. Baseline data were expressed as means ± standard deviations. Chi-square test was applied to compare the categorical variable. Differences between two groups were evaluated with independent samples t-test. A value of P < 0.05 was considered as statistically significant.
| Results|| |
The general characteristics of the women are shown in [Table 1]. The mean age of all the women (n = 256) was 27.88 ± 4.53 years. The majority of the normal weight and obese women were homemakers (94.4% vs. 93.6%, respectively). Obesity was in urban women higher than rural women (55.1% vs. 44.9%), and this difference was significant (P < 0.021). The average duration of menstruation in normal weight and obese women was 6.16 ± 1.37 and 6.09 ± 1.42, respectively [Table 2].
|Table 1: Demographic characteristics and body mass index of the participants|
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A summary of the laboratory and BMI characteristics of the total sample of women is presented in [Table 3]. There was found no association between hematological characteristics and BMI [Table 3].
|Table 3: Laboratory characteristics of the participants according to body mass index|
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The data showed that only 13.4% of obese women and 17.1% of the women with normal weight had IDA (odds ratio = 0.75; 95% confidence interval: 0.39–1.49). There was no significant difference in the ferritin, serum iron and TIBC between the two groups.
| Discussion|| |
Obesity is recently considered a universal pandemic, while ID maintains to be the most prevalent single micronutrient deficiency in the world. ID, in developed countries, is the most popular nutritional deficiency and has been linked to obesity in adults and children. This is of noticeable fear for the health of the population given that obese people are at enhanced danger for morbidities, functional decrease, impaired quality of life, promoted use of health-care sources, and increased mortality.
The results of our study showed no significant difference of anemia in the two groups of obese and normal weight, and it was not significant clinically.
Furthermore, Laillou et al. reported BMI category was not associated with ID anemia or folate status. Other study showed no difference in plasma iron and TIBC in normal weight and obese women, and obese women of reproductive age have higher iron stores than the nonobese women. Al-Hashem's study showed that the mean Hb level was positively associated with WC and negatively associated with BMI. In another study, the prevalence of ID was 9% in the overweight group, and no true ID cases were recorded in the overweight and obese groups. Paknahad et al. reported a significant correlation between BMI quartile, Hb, and Hct. Other studies showed that mean Hb and plasma ferritin concentrations were significantly greater in obese weight and high BMI. Hct was also significantly greater in higher BMI quartiles.,,,
On the other hand, other study showed that overweight adults had lower iron compared with normal weight persons. Neymotin and Sen reported a negative correlation between levels of iron blood content and individual BMI after controlling for other individual characteristics. Other studies results indicated that heavier-weight female adolescents are at greater risk for ID.,,
Mujica-Coopman et al. reported that FE absorption was lower in obese in another study, women than overweight and normal weight women; they had more serum ferritin (P < 0.01) and Hb (P < 0.05) concentrations.
Therefore, they stated that lower FE absorption may be due to subclinical inflammation associated with obesity. Menzie et al. found that the obese and the nonobese individuals did not differ in total daily iron consumption, but the fat mass was a significant negative predictor of serum iron level. Furthermore, in another study an increase of BMI has been associated with low serum iron and Hb as well as high serum ferritin levels.
In our study, the low level of anemia in two groups may be due to the low number of gravity and parity.
The results of our study showed no significant difference in reproductive and demographic information in the two groups of obese and normal weight, but the obesity rate was lower in rural women. Furthermore, in another study, age, menarche, and poverty status were similar between the two groups and were not independent predictors of ID or serum iron levels.
Whereas Paknahad et al. showed a significant correlation between BMI and parity (r = 0.0102 and P = 0.007) and BMI higher among the urban women. In other study by Amirkhizi et al., BMI was positively associated with age (r = 0.32, P < 0.0001) and number of pregnancy (r = 0.26, P < 0.003). Furthermore, Patil et al. reported that 41.9% of study participants were anemic, and there was a significant association of anemia with educational status.
Obesity is generally correlated with more nutrition and ID with lower nutrition. ID might outcome from the increased iron demand of obese people because of their larger blood volume and their utilization of energy-dense, nutrient-poor foods.
It seems that the relationship between obesity and IDA is controversial. Therefore, further studies are needed to be done.
These researches may be explained by the low-grade chronic inflammation of obesity and have been implicated in many obesity-related difficulties. In our study, the lower rate of obesity in rural women can be due to more activity. Therefore, urban women should be encouraged to activity and exercise. The limitation of our study was that the sampling only included nonpregnant women, nonlactating, and healthy participants without any history of illness or drug use, and the sampling was hardly done.
| Conclusions|| |
Comparing our study with other studies showed that the relationship between obesity and IDA is controversial. Therefore, we suggest that future investigation should be designed on the women of reproductive age with an emphasis on food intake.
The authors would like to thank Babol University of Medical Sciences and the study participants for their support. Furthermore, the authors acknowledge the very helpful contributions of the reviewers to the quality of the final manuscript.
Financial support and sponsorship
This study was supported by a research grant from the Babol University of Medical Sciences (Grant Number: 76344/29).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bhowmik B, Munir SB, Diep LM, Siddiquee T, Habib SH, Samad MA, et al
. Anthropometric indicators of obesity for identifying cardiometabolic risk factors in a rural bangladeshi population. J Diabetes Investig 2013;4:361-8.
Lear SA, Teo K, Gasevic D, Zhang X, Poirier PP, Rangarajan S, et al
. The association between ownership of common household devices and obesity and diabetes in high, middle and low income countries. CMAJ 2014;186:258-66.
Chung B, Matak P, McKie AT, Sharp P. Leptin increases the expression of the iron regulatory hormone hepcidin in huH7 human hepatoma cells. J Nutr 2007;137:2366-70.
Choudhry VP. Hepicidin and its role in iron metabolism. Indian J Pediatr 2010;77:787-8.
del Giudice EM, Santoro N, Amato A, Brienza C, Calabrò P, Wiegerinck ET, et al
. Hepcidin in obese children as a potential mediator of the association between obesity and iron deficiency. J Clin Endocrinol Metab 2009;94:5102-7.
Przybyszewska J, Zekanowska E, Kedziora-Kornatowska K, Boinska J, Cichon R, Porzych K, et al
. Prohepcidin and iron metabolism parameters in the obese elderly patients with anemia. J Nutr Health Aging 2011;15:259-64.
Benoist BD, McLean E, Egll I, Cogswell M. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia. Worldwide Prevalence of Anaemia 1993-2005: WHO Global Database on Anaemia; 2008.
Zekanowska E, Boinska J, Giemza-Kucharska P, Kwapisz J. Obesity and iron metabolism. BioTechnol J Biotechnol Comput Biol Bionanotechnol 2011;92: 147-152
Cheng HL, Bryant C, Cook R, O'Connor H, Rooney K, Steinbeck K, et al
. The relationship between obesity and hypoferraemia in adults: A systematic review. Obes Rev 2012;13:150-61.
Manios Y, Moschonis G, Chrousos GP, Lionis C, Mougios V, Kantilafti M, et al
. The double burden of obesity and iron deficiency on children and adolescents in Greece: The healthy growth study. J Hum Nutr Diet 2013;26:470-8.
Low S, Chin MC, Deurenberg-Yap M. Review on epidemic of obesity. Ann Acad Med Singapore 2009;38:57-9.
Ribot B, Ruiz-Díez F, Abajo S, March G, Fargas F, Arija V, et al
. Prevalence of anaemia, risk of haemoconcentration and risk factors during the three trimesters of pregnancy. Nutr Hosp 2018;35:123-30.
Habib MA, Raynes-Greenow C, Soofi SB, Ali N, Nausheen S, Ahmed I, et al
. Prevalence and determinants of iron deficiency anemia among non-pregnant women of reproductive age in Pakistan. Asia Pac J Clin Nutr 2018;27:195-203.
Ghose B, Yaya S, Tang S. Anemia status in relation to body mass index among women of childbearing age in Bangladesh. Asia Pac J Public Health 2016;28:611-9.
Anderson AK. Prevalence of anemia, overweight/Obesity, and undiagnosed hypertension and diabetes among residents of selected communities in Ghana. Int J Chronic Dis 2017;2017:7836019.
Datz C, Felder TK, Niederseer D, Aigner E. Iron homeostasis in the metabolic syndrome. Eur J Clin Invest 2013;43:215-24.
Myint PK, Kwok CS, Luben RN, Wareham NJ, Khaw KT. Body fat percentage, body mass index and waist-to-hip ratio as predictors of mortality and cardiovascular disease. Heart 2014;100:1613-9.
Svensson EM. The Preventive Effect of Exercise on Gestational Glucose Tolerance-Timing, Frequency, Duration and Intensity of Exercise Before, Early and Late in Pregnancy: NTNU; 2017.
Aigner E, Feldman A, Datz C. Obesity as an emerging risk factor for iron deficiency. Nutrients 2014;6:3587-600.
Kasper D, Fauci A, Hauser S, Longo D, Larry Jameson LJ, Loscalzo J. Harrison's Principles of Internal Medicine. 19th
ed., Vol. 2. New York: McGraw Hill Education; 2015.
Mujica-Coopman MF, Brito A, López de Romaña D, Pizarro F, Olivares M. Body mass index, iron absorption and iron status in childbearing age women. J Trace Elem Med Biol 2015;30:215-9.
Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012;70:3-21.
Amato A, Santoro N, Calabrò P, Grandone A, Swinkels DW, Perrone L, et al
. Effect of body mass index reduction on serum hepcidin levels and iron status in obese children. Int J Obes (Lond) 2010;34:1772-4.
Laillou A, Yakes E, Le TH, Wieringa FT, Le BM, Moench-Pfanner R, et al
. Intra-individual double burden of overweight and micronutrient deficiencies among Vietnamese women. PLoS One 2014;9:e110499.
Amirkhizi F, Siassi F, Djalali M, Minaie S. Assessment of body mass index and its relationship with iron status indices among women in rural areas of Kerman Province, Iran. Koomesh 2007;9:41-6.
Al-Hashem FH. Is it necessary to consider obesity when constructing norms for hemoglobin or when screening for anemia using hemoglobin levels? Saudi Med J 2007;28:41-5.
Fanou-Fogny N, J Saronga N, Koreissi Y, Dossa RA, Melse-Boonstra A, D Brouwer I, et al
. Weight status and iron deficiency among urban Malian women of reproductive age. Br J Nutr 2011;105:574-9.
Paknahad Z, Omidvar N, Mahboub S, Afiat MS, Ostad RA, Ebrahimi MM. Body mass index of reproductive age group women and it's relationship with iron status. JTUMS 2001;35:17-23.
Tussing-Humphreys LM, Liang H, Nemeth E, Freels S, Braunschweig CA. Excess adiposity, inflammation, and iron-deficiency in female adolescents. J Am Diet Assoc 2009;109:297-302.
Qin Y, Melse-Boonstra A, Pan X, Yuan B, Dai Y, Zhao J, et al
. Anemia in relation to body mass index and waist circumference among Chinese women. Nutr J 2013;12:10.
Ausk KJ, Ioannou GN. Is obesity associated with anemia of chronic disease? A population-based study. Obesity (Silver Spring) 2008;16:2356-61.
Neymotin F, Sen U. Iron and obesity in females in the United States. Obesity (Silver Spring) 2011;19:191-9.
Shekarriz R, Vaziri MM. Iron profile and inflammatory status of overweight and obese women in Sari, North of Iran. Int J Hematol Oncol Stem Cell Res 2017;11:108-13.
Stankowiak-Kulpa H, Kargulewicz A, Styszyński A, Swora-Cwynar E, Grzymisławski M. Iron status in obese women. Ann Agric Environ Med 2017;24:587-91.
Abbas W, Adam I, Rayis DA, Hassan NG, Lutfi MF. Higher rate of iron deficiency in obese pregnant Sudanese women. Open Access Maced J Med Sci 2017;5:285-9.
Menzie CM, Yanoff LB, Denkinger BI, McHugh T, Sebring NG, Calis KA, et al
. Obesity-related hypoferremia is not explained by differences in reported intake of heme and nonheme iron or intake of dietary factors that can affect iron absorption. J Am Diet Assoc 2008;108:145-8.
Altunoǧlu E, Müderrisoǧlu C, Erdenen F, Ulgen E, Ar MC. The impact of obesity and insulin resistance on iron and red blood cell parameters: A single center, cross-sectional study. Turk J Haematol 2014;31:61-7.
Patil S, Wasnik V, Wadke R. Health problems amongst adolescent girls in rural areas of Ratnagiri district of Maharashtra, India. J Clin Diagn Res 2009;3:1784-90.
Cepeda-Lopez AC, Aeberli I, Zimmermann MB. Does obesity increase risk for iron deficiency? A review of the literature and the potential mechanisms. Int J Vitam Nutr Res 2010;80:263-70.
[Table 1], [Table 2], [Table 3]