anemia is a public health issue for developing countries , especially for child bearing age women . the worldwide prevalence of anemia in child bearing age group is quite high ( 30.2% ) . according to world health organization ( who ) report , 32.3% nonpregnant women of child bearing age are suffering from anemia in saudi arabia . alquaiz conducted a hospital - based study and found 37% of women suffering from anemia in riyadh , saudi arabia . anemia is a multifactor disease and can act both as a risk factor or a consequence of a disease . these may range from ethnicity , gender , age , sociodemographic status , dietary habits , physical and mental health , gynecological / obstetric history , cancers , and anticancerous drugs to genetic makeup . specific risk factors include deficiency of iron , worm infestation , repeated pregnancies , menorrhagia , postpartum hemorrhage , gastric ulcers , hemorrhoids , intake of aspirin / nonsteroidal anti - inflammatory drugs , and pure vegetarian diet . controversial results from long- and short - term intervention studies on the role of different food inhibitors ( tea , coffee , bran , and egg yolk ) and enhancers ( meat , and dairy products , and ascorbic acid ) on iron absorption and iron stores have raised questions regarding their effectiveness in reducing anemia [ 4 , 5 ] . it follows the life cycle approach where each stage of life is affected . inside the mother 's womb it decreases fetus ' physical growth and may cause mental growth retardation ; during childhood it affects cognitive growth and development ; during adult hood it decreases physical work capacity , and finally in elderly it affects the quality of life [ 613 ] . in addition , in severe cases it may lead to maternal and infant mortality [ 912 ] . alquaiz found that dietary habits ( infrequent intake of meat and juices ) , menorrhagia , intake of antacids , and nonsteroidal anti - inflammatory drugs were the most frequent correlates of anemia in saudi women of child bearing age . institution / hospital - based studies are available [ 2 , 14 , 16 ] regarding prevalence and risk factors for anemia but are subjected to selection bias and may not be generalizable ; therefore , reassessing anemia through primary care / community - based approach is a crucial component of public health research . the objective of present survey was to measure the prevalence and risk factors for anemia in women of child bearing age in riyadh , saudi arabia . this survey covered whole riyadh region with a population of 3,726,523 saudi persons ( ministry of planning , preliminary results of 1425 hijri ( 2004 ) census ) . the study was approved by the institutional review board , king saud university , and funded by ministry of health , kingdom of saudi arabia . sample size was calculated on the assumption of 32% prevalence of iron deficiency anemia ( ida ) in riyadh . at 95% confidence level and acceptance of 3% as degree of precision , we used two - stage cluster sampling technique along with a design effect of 2 which increased the sample size to 1000 women . we expected 20% refusal rate which further increased the sample size to 1,200 women . for risk factor analysis , assuming a type i error of 0.05 , type ii error of 0.20 ( power of 0.80 ) , and 25% difference in prevalence of risk factors among anemic and nonanemic women , we needed 500 women in each group . in the first stage a complete list of clusters ( cluster defined as catchment area surrounding a primary health care center ( phcc ) ) was formulated . five clusters were randomly selected from each of the five administrative regions of riyadh city , so in total there were 25 clusters . assuming that an average saudi family in riyadh region will have at least one child bearing age woman in their house , 4550 houses were randomly selected from each cluster . if more than one eligible woman present in a house , all were invited to participate and visit the phcc . inclusion criteria were ; nonpregnant , age between 15 and 49 years , understanding and speaking arabic , and resident of riyadh city , saudi arabia . 1500 women were initially enrolled out of which 71 ( 5% ) were excluded as they were either pregnant or lactating . figure 1 is representing the flow chart on the number of child bearing age women enrolled in the study . it inquired about sociodemographic characteristics ( age , education , occupation , and type of resident ) ; obstetric and gynecological history ( menstrual history including frequency , duration and flow during menstrual cycle , contraceptive use and its duration , obstetric history on abortions , pregnancies , number of children , birth interval , and hysterectomy ) ; family history of iron deficiency anemia and smoking history ; dietary factors ( inquired about regular ( at least 5 days per week ) intake of red meat , vegetables , eggs , tea or coffee , fresh juices , beverages , and diluted yogurt ) ; and past medical conditions associated with anemia ( peptic ulcer , hemorrhoids , cancer , bilharzias , personal and family history of iron deficiency anemia , and blood transfusion ) . body mass index ( bmi ) was calculated using formula weight in kg / height in meter , and the number of women belonging to following categories was calculated : underweight < 18.5  kg / m , normal > 18.524.9 kg / m , overweight 2529.9  kg / m , and obese 30  kg / m . 5  cc venous blood sample was taken for complete blood count including hemoglobin , red blood cells , hematocrit , and red cell indices , for example , mean cell volume , mean cell hemoglobin , mean cell hemoglobin concentration , and red blood cells distribution width . after collection blood was immediately transferred into labeled and prepared tubes containing edta or heparin . these were sent to the laboratory where hemoglobin estimation was performed by the laboratory technicians using unicel dxlt 800 , coulter cellular analysis system ( beckman coulter inc . light scatter method was adopted to measure hemoglobin and red cell indices under the supervision of a hematologist . quality control procedures ( coulter 6c cell control ) as instructed by the manufacturer were followed . anemia was defined according to world health organization ( who ) hemoglobin level of < 12  g / dl . data were analyzed using spss computer statistical software package ( ibm spss statistics version 19 ) . the outcome variable was dichotomized as anemic and nonanemic based on who cutoff of < 12  g / dl . age and bmi were taken as continuous , whereas number of children , birth interval , menstrual flow , dietary habits and disease status were taken as binary variables . multiple logistic regression was performed using enter method to identify important factors associated with anemia among child bearing age women . the mean hemoglobin of 969 women was 12.35 ( 1.80 )  g / dl , 95% ci 12.2412.46 and interquartile of range 1.9 . table 1 is presenting the mean , minimum , maximum , and interquartile range for mean corpuscular volume ( mcv ) [ fl ] , mean corpuscular hemoglobin ( mch ) [ pg ] and mean corpuscular hemoglobin concentration ( mchc ) , and red blood cell width ( rdw ) of 969 women . mean ( sd ) value for mch , mcv , mchc and rdw were 79.21 ( 12.17 )  fl , 26.37 ( 6.21 )  pg , 32.36 ( 4.91 )  g / dl and 14.84 ( 4.65)% , respectively . although we did not measure the gold standard serum ferritin levels , low mean levels of these indices point towards iron deficiency anemia ( ida ) . study conducted by alquaiz et al . found mcv , mch , and rdw as reliable , cost - effective , and useful parameters to detect iron deficiency anemia in child bearing age women in absence of serum ferritin level . the mean hemoglobin in anemic group and normal group was 10.81 ( 1.24 ) and 13.38 ( 1.31 ) g / dl , respectively ( p < 0.01 ) . these findings are consistent with other local and regional studies [ 13 ] . in fact the figure of 40% is higher than the previous who estimates and according to international definition countries with 40% prevalence   belongs to the group of countries with anemia as a severe public health problem rather than moderate or mild . . we found 1% ( 3 ) , 2% ( 9 ) , 14% ( 54 ) , and 83% ( 322 ) suffering from very severe ( < 4  g / dl ) , severe ( < 8  g / dl ) , moderate ( < 10  g / dl ) , and mild ( < 12  g / dl ) anemia , respectively . prevention in the early mild stages can help in reducing future burden of moderate and severe anemia . table 3 is representing the unadjusted odds ratio of significant variables . among significant factors we found increasing bmi ( or 0.97 , 95% ci 0.95 , 0.98 ) , absence of clots ( or 0.65 , 95% ci 0.47 , 0.89 ) , absence of flooding during menstruation ( or 0.69 , 95% ci 0.48 , 0.96 ) , number of children ( or 1.52 , 95% ci 1.02 , 2.23 ) , birth interval ( or 2.23 , 95% ci 1.20 , 4.41 ) , not eating red meat ( or 1.28 , 95% ci 1.02 , 1.66 ) , not drinking diluted yogurt ( or 1.30 , 95% ci 1.01 , 1.69 ) , and presence of personal ( or 2.74 , 95% ci 1.79 , 4.19 ) and family history of ida ( or 2.55 , 95% ci 1.63 , 3.98 ) associated with anemia ( table 4 ) . no significant association was found with sociodemographic variables , age at menarche , contraceptive use , juices , egg , vegetables , tea or coffee , peptic ulcer , hemorrhoid , and previous history of blood transfusion or hereditary blood disorders . multivariate logistic regression analysis revealed that infrequent ( 2 times per week ) intake of meat ( or 1.59 , 95% ci 1.082.48 ) was associated with anemia ( table 4 ) . healthy and correct diet prevents anemia , especially in child bearing age women . dietary iron comprises of heam and nonheam iron . heam iron is mainly available through meat intake and may be absorbed up to 50% , whereas nonheam iron mainly available through fruits , vegetables , dairy products ( milk , butter , yogurt ) is variable and depends upon enhancers and inhibitors for iron absorption . absorption of nonheam iron increases in presence of meat , poultry , sea food , and juices with vitamin c , whereas tea , coffee , and egg yolk act as inhibitors towards iron absorption [ who ] [ 19 , 20 ] . we found that those having high bmi are protective and have 5% less risk of developing anemia ( or 0.95 ; 95% ci 0.920.97 ) as compared to those with low bmi . our findings support that good diet intake improves the energy supply and provides the body with nutrients making it strong and resistant against acquiring diseases ; however high , caloric intake does not ensure micronutrient deficiency , and people with high bmi may suffer from anemia . strong association was found with family history of iron deficiency anemia ( or 2.64 , 95% ci 1.275.09 ) . if anemia is diagnosed even in a single family member , all other members should undergo screening to identify the cause and prevent future grave consequences . we ran a second model with women ( n = 466 ) having children ( not shown ) . women having 5 or more children were almost twice at risk of developing anemia as compared to women having < 5 children ( or 1.85 ( 95% ci 1.033.54 ) ) . number of children and birth intervals are established risk factors for anemia [ 2225 ] . our study found moderate but insignificant negative correlation between number of children and birth interval . during pregnancy and delivery the iron stores are depleted and women do require additional iron supplements to cover the body and fetus needs [ 1 , 3 ] . we found more the number of children , shorter the birth intervals ( < 1 year ) , hence depriving the woman 's body of an appropriate interval during which it can revive its baseline energy stores level . our study has some limitations . around 30% of women visiting the phcc and filling the questionnaire refused to give the blood sample for hemoglobin mainly due to fear of getting a needle prick however , the characteristics of those women who refused to give blood sample were not different from those who gave blood sample , and we are justified in stating that it was a representative sample . information bias may be present as past family and personal history of iron deficiency anemia was based on patient 's verbal response . in addition , it is possible that residual uncontrolled confounding may have played a role in our findings . current study found higher prevalence of anemia in child bearing age women than by previous studies . mass interventions through large - scale community and primary care health programs focusing on awareness of proper and healthy diet and reproductive health will help in reducing burden of anemia . further studies are needed to explore the specific type of anemia and interventional studies to study the effect of different dietary supplements on iron stores .
objective . to determine the prevalence and risk factors for anemia in child bearing age women in riyadh , saudi arabia 
 . design . 
 cross - sectional survey was conducted using two - stage cluster sampling . 
 25 clusters ( primary health care centers ( phcc ) ) were identified from all over riyadh , and 4550 households were randomly selected from each cluster . 
 eligible women were invited to phcc for questionnaire filling , anthropometric measurements , and complete blood count . 
 blood hemoglobin was measured with coulter cellular analysis system using light scatter method . setting . 
 phcc . subjects . 
 969 ( 68% ) women out of 1429 women were included in the analysis . 
 results . 
 mean hemoglobin was 12.35 ( 1.80 )  g / dl , 95% ci 12.2412.46 with interquartile range of 1.9 . 
 anemia ( hb < 12  g / dl ) was present in 40% ( 390 ) women . 
 mean ( sd ) for mch , mcv , mchc , and rdw was 79.21 ( 12.17 )  fl , 26.37 ( 6.21 )  pg , 32.36 ( 4.91 )  g / dl , and 14.84 ( 4.65)% , respectively . 
 multivariate logistic regression revealed that having family history of iron deficiency anemia ( or 2.91 , 95% ci 1.784.76 ) and infrequent intake of meat ( or 1.54 , 95%ci 1.152.05 ) were associated with increased risk of anemia , whereas increasing body mass index ( or 0.95 , 95% ci 0.920.97 ) was associated with reduced risk of anemia . 
 conclusion . 
 women should be educated about proper diet and reproductive issues in order to reduce the prevalence of anemia in saudi arabia .