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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 2  |  Page : 43-48

Prevalence of anemia and iron status among nomadic Fulani children in a grazing reserve in Northwestern Nigeria


1 Department of Hematology and Blood Transfusion, Kaduna State University, Kaduna, Nigeria
2 Department of Hematology and Blood Transfusion, Ahmadu Bello University, Zaria, Nigeria

Date of Web Publication19-Mar-2019

Correspondence Address:
Dr. Halima Bello-Manga
Department of Haematology and Blood Transfusion, Kaduna Sate University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_18_18

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  Abstract 

Introduction: Iron is one of the most important micronutrients that play a vital role in hemoglobin (Hb) synthesis, cellular metabolism, and psychomotor function in humans. Iron deficiency is a major cause of anemia worldwide, particularly in children. The nomadic Fulanis have a migratory lifestyle determined by the availability of water and pasture for their livestock, making them difficult to reach, thus the paucity of knowledge on their health status. Objectives: To assess the Hb concentration, red cell indices, serum ferritin, and transferrin receptor levels among nomadic Fulani children in Ladduga grazing reserve of Kaduna state, Nigeria. Materials, Subjects, and Methods: This was a cross-sectional, descriptive study using questionnaires and physical examination of 340 children (5–15 years). Their complete blood count was determined by automation; serum ferritin and soluble transferrin receptor (sTFR) levels were assayed using enzyme-linked immunosorbent assay technique. Data obtained was analyzed using SPSS version 20.0. Level of significance was set at P ≤ 0.05. Results: The prevalence of anemia was 40.3%, which was significantly higher among the children aged 5–9 years (54.7%) compared to 30.5% in the 10–15 years age group (Z-statistic = 4.5, P= <0.001). Iron deficiency anemia was observed in only 19 (5.6%) of the study population. Median (interquartile ranges) serum ferritin and mean ± standard deviation sTFR levels were 56.0 (55.8) μg/L and 34.73 ± 14.29 nmol/L, respectively. Majority (77.4%) of the participants had normal iron stores and only 18.8% had low stores. Among the 137 participants with anemia, 19 (13.9%), 76 (55.5%), 102 (74.5%), and 76 (55.5%) had serum ferritin <30 μg/L, sTfR > 28.1 nmol/L, mean corpuscular volume <80 fl, and mean corpuscular hemoglobin <27 pg, respectively. Conclusion: There is a high prevalence of anemia among nomadic Fulani children at Ladduga grazing reserve. However, iron deficiency is not the only cause of anemia.

Keywords: Children, hemoglobin, iron, nomadic Fulanis, red cell indices


How to cite this article:
Bello-Manga H, Awwalu S, Ijei IP, Hassan A, Mamman AI. Prevalence of anemia and iron status among nomadic Fulani children in a grazing reserve in Northwestern Nigeria. Arch Med Surg 2018;3:43-8

How to cite this URL:
Bello-Manga H, Awwalu S, Ijei IP, Hassan A, Mamman AI. Prevalence of anemia and iron status among nomadic Fulani children in a grazing reserve in Northwestern Nigeria. Arch Med Surg [serial online] 2018 [cited 2019 Apr 24];3:43-8. Available from: http://www.archms.org/text.asp?2018/3/2/43/254572


  Introduction Top


Anemia is a global health problem with an estimated prevalence of 32.9%.[1] The regions with the highest burden are Asia and Sub-Saharan Africa with a prevalence of 37.5% and 23.9%, respectively, and children bearing the highest brunt.[1] The three main causes of anemia include iron deficiency, hemoglobinopathies, and malaria infection.[2] Iron deficiency anemia is said to be the cause of more than half of anemias worldwide.[3],[4] In children in Sub-Saharan Africa, causative factors include low dietary intake, poor dietary absorption,[3] and chronic blood loss from parasitic infestation.[5],[6] Nomadic Fulani children are at risk of developing anemia due to their lifestyle of walking barefoot, consumption of diet low in protein, and exposure to mosquitoes. In addition to this, poor access to health promotion interventions such as environmental sanitation, vaccination, appropriate nutritional support, and potable water, coupled with a migratory lifestyle, accentuates the risk of anemia in this vulnerable group.

Anemia is a symptom, not a diagnosis, and complete blood count (CBC) is of immense importance in the evaluation of its cause and the type of anemia in different situations. Red cell indices are derived from the CBC, and this forms a basis for the morphological classification of anemia.[7],[8] In the assessment of iron status, low hemoglobin (Hb) in the presence of low red cell indices is highly indicative of iron deficiency; however, this may be normal in early stages of iron deficiency. A similar finding may also be seen in thalassemia; thus the need to further confirm the actual amount of iron in the reticuloendothelial stores, which is mirrored by the level of serum ferritin. Serum ferritin has been considered by the World Health Organization (WHO) to be the best indicator of iron intervention and a useful indicator for depleted iron stores.[9] The major drawback for serum ferritin is being an acute phase reactant; therefore, its synthesis is increased in many inflammatory conditions and infections.[9] However, because of other confounding factors associated with its measurement, the WHO has suggested that the threshold be increased to <30 μg/L in the presence of infections.[9]

The measurement of serum ferritin together with transferrin receptor levels provides a good index of iron status of a population.[9] This is because transferrin receptor levels do not rise in the presence of inflammatory conditions, as ferritin does; therefore, it can be used to detect iron deficiency in the presence of such conditions.[9],[10]

This study was to determine the prevalence of anemia and iron status among nomadic Fulani children in Ladduga grazing reserve, Kaduna state, Nigeria.


  Materials, Subjects, and Methods Top


Study setting

The Ladduga grazing reserve in the Ikulu Chiefdom of Kachia local government area of Kaduna state, Nigeria, is home to eight villages, namely Wuro Nyako, Nasarawa, Wuro Fulɓe, Wuro Modi, Wuro Saleh, Tilɗe Bayero, Mayo Borno, and Ladduga. The tropical climate on the undulating plains with occasional rocky hillocks sustains the Guinea Savannah Vegetation. The reserve is situated between 600 and 750 m above sea level and has as an area of 30,956 km2. The grazing reserve has a human population of about 18,000 and an animal population of 50,503 made up of cattle, sheep, goats, donkeys, and poultry. These numbers often diminish in the dry season due to Southward migration of the people and their animals in search for pasture.[11] Facilities provided at the reserve include earth dams, boreholes, community health clinic, community school, veterinary clinic, and milk collection center. The primary occupation of the population is cattle breeding and farming during the rainy season. The men and adolescent male children usually conduct herding, while women and girls are engaged in household chores, craftwork, processing and selling dairy products, fetching water, firewood, and tending to the vegetable gardens.

The study was carried out on nomadic Fulani children, of consenting parents and guardians, between the ages of 5 and 15 years living within Ladduga grazing reserve.

Study participants

A total of 340 participants were selected using the cluster sampling method. The eight villages within the grazing reserve were used as clusters. Four out of the eight villages were selected randomly, using the balloting technique. Participants, proportionate to the size of the population, were selected from each chosen cluster. A list of all the households in each chosen cluster served as the sampling frame. The children were randomly selected from these houses, and the village head's (Ardo's) house was used as the starting point. Subsequently, every second house on the right of the village head's house was selected until the required number of participants in each village was obtained. This was replicated in all the villages selected.

Ethical consideration

Ethical approval for this study was obtained from the Ahmadu Bello University Teaching Hospital, Health Research Ethics Committee. A preliminary visit was conducted to the study area where a meeting, headed by the “Ardo” (i.e., district head), was held with the gatekeepers of the community and rapport was established. After this, the purpose of the study and the process of sample collection were explained to the gatekeepers and the parents of children and their children in the languages that they understood (Hausa and Fulfulde). They were also told that they could decline participation without repercussions. All cost of the research was borne by the researchers.

Sample collection

Under standard aseptic techniques described by Jury et al.,[12] 5 ml of blood was collected from a prominent antecubital vein, 2.5 ml was dispensed into an anticoagulant bottle (ethylene diamine tetra acetic acid) for CBCs using Sysmex KX-21N (Sysmex Corporation, Kobe, Japan), while 2.5 ml was dispensed into another plain bottle for enzyme-linked immunosorbent assay (ELISA). Serum ferritin and soluble transferrin receptor (sTFR) levels were assayed using micro-well ELISA human ferritin enzyme immunoassay by Diagnostic Automation, Inc. (USA) and Quantikine® IVD® ELISA human sTFR by R and D Systems Inc. kits, respectively.

Definition of terms

Anemia was defined as a Hb concentration of <11.5 g/dl.[13] Hypochromia, microcytosis, and macrocytosis were defined as mean corpuscular hemoglobin (MCH) <27 pg, mean corpuscular volume (MCV) <80 fl, and MCV >95 fl, respectively.[13]

The range for normal serum ferritin level which is reflective of the iron stores was 20–300 μg/L.[14] However, for this study, depleted and high levels were defined as <30 and >300 μg/L, respectively.

Iron deficiency anemia was defined as Hb < 11.5 g/dl in the presence of low serum ferritin (<30 μg/L).[9] This serum ferritin cutoff value for depleted iron stores, although suggested for <5-year-olds in settings of inflammation and infection, was used in this study due to the absence of agreement on values for ≥5-year-olds in similar settings.[9] More so, markers of inflammation were not assessed in this study. Normal range for sTfR used was 8.7–28.1 nmol/L.[15]

Data analysis

A structured questionnaire was administered to participants with parents/guardians as respondents. The questionnaires had sections on sociodemographic data and results of investigation. Data were checked for completeness and analyzed using SPSS version 20.0 (IBM, Armonk, NY). Continuous variables were summarized as means and standard deviations or medians and interquartile ranges for normally and nonnormally distributed variables, respectively. Categorical variables were presented as percentages. While means were compared using t-tests, medians were compared using independent samples median tests. Proportions were compared using Z-tests for proportions. Spearman correlation analyses were conducted to assess the relationship between serum ferritin and sTfR levels. Level of significance was set at P ≤ 0.05.


  Results Top


There were 340 participants aged between 5 and 15 years who were enrolled with females constituting 190 (55.9%). The participants were stratified into 5–9 years (186/340, 54.7%) and 10–15 years (154/340, 45.3%). Other sociodemographic data are as summarized in [Table 1]. A summary of parameters assessed is provided in [Table 2], while hematologic parameters and iron status by age and sex are summarized in [Table 3] and [Table 4].
Table 1: Sociodemographic characteristics of respondents

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Table 2: Overall summary statistics

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Table 3: Hematologic parameters by age with mean and standard deviation

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Table 4: Hematologic parameters by sex with mean and standard deviation

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The overall prevalence of anemia was 40.3% (137/340). Younger children (5–9 years) had significantly higher prevalence of anemia than those in the 10–15 years category (75/137 [54.7%] vs. 62/203 [30.5%], Z-statistic = 4.5, P = <0.001). The burden of anemia was comparable between boys and girls (67/150 [44.7%] vs. 70/190 [36.8%], Z-statistic = 1.5, P = 0.140). Microcytic anemia was found in 102/340 (30.0%) while 76/340 (22.4%) had hypochromic anemia. Majority 263 (77.4%) of the participants had normal iron stores [Figure 1]. sTFR levels were high, normal, and low in 185 (54.4%), 76 (22.4%), and 79 (23.2%) of the participants, respectively. There was a negative, weak nonstatistically significant correlation between serum ferritin and sTfR levels (rho = −0.101, P = 0.063). Iron deficiency anemia was found in 19/340 (5.6%) of the children. Among the 137 participants with anemia. 19 (13.9%), 76 (55.5%), 102 (74.5%), and 76 (55.5%) had serum ferritin <30 μg/L, sTfR >28.1 nmol/L, MCV < 80 fl, and MCH <27 pg, respectively.
Figure 1: Distribution of serum ferritin among all participants (n = 340)

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  Discussion Top


The high prevalence of anemia in this study is consistent with reports of similar studies,[10],[16] and the findings by Asobayire et al. among settled rural schoolchildren in Côte d'Ivoire[10] and Hashizume et al. in Kazakhstan,[16] who reported 46.0% and 49.8%, respectively. This is higher than the global prevalence for anemia (24.5%)[17] in schoolchildren. However, a higher prevalence of 82.6% was reported by Onimawo et al.[18] in 2010 among settled school-aged children in Abia State, Southeastern Nigeria. The prevalence of anemia in this study is within the category of severe public health significance of the WHO as it is above 40.0%.[19] The finding in this study is in keeping with the report that children in Sub-Saharan Africa bear a high burden of anemia,[1] which could be physiological, due to increased growth demand for iron and other essential nutrients that is often unmet. It may be pathological through blood loss from helminthic infestation as well as other causes of anemia such as hemoglobinopathies and malarial infection.[2] A study in the same population by Bello-Manga et al. showed a prevalence of helminthic infestation to be 14.4% with the hookworm species as the most common soil-transmitted helminth.[20]

This study revealed comparably low Hb concentration among boys and girls. The predominance of anemia among 5–9 years old in this study is similar to the report of El Hioui et al. on rural school-aged children in Morocco, where they found a prevalence of 16.3% among younger children as against 7.3% in the older children.[21] The reason for this could be that the younger children are prone to infections and have less access to nutritious foods compared to the older children, who tend to fend for themselves better.

The high prevalence of hypochromic anemia and microcytic anemia demonstrated by this study is comparable to the report by Fleming and Werblińska in Zaria, where they reported hypochromia in 25% of the children.[22] Our finding is, however, lower than the figure reported by Adebara et al. in Ilorin, who reported a prevalence of 47.6%.[23] A study conducted by Hows et al.[24] showed that hypochromia and microcytosis are common findings in children, but this is not always due iron deficiency or hemoglobinopathies; they suggested that it is an intrinsic feature of erythropoiesis in children and its independent of iron status.[24]

Data from this study suggest that most of the participants have normal iron stores as reflected by the level of serum ferritin [Figure 1]. However, the prevalence of iron deficiency in this study is higher than that found by Adebara et al. on school-aged children in Ilorin which was 3.7%[23] and that reported by Jeremiah et al.,[25] who found a prevalence of 13.8% among children aged 1–8 years in Port Harcourt. Higher prevalence rates, however, reported by Onimawo et al. and Fleming and Werblińska were 77.8% and 60.0%, respectively.[18],[22] Prual et al. also reported the prevalence of iron deficiency to be 47.1% among rural school-aged children in Niger Republic,[26] and a prevalence of 31.2% was found among school-aged children in Northern Kenya.[27]

The gold standard for diagnosing iron deficiency is the assessment of stainable iron in the bone marrow;[28] however, it is an invasive procedure. On the other hand, assessment of iron status using serum ferritin in the setting of inflammation and infections is challenging because as an acute phase reactant, levels can be confounded by inflammation.[28] It is recommended that the measurements of serum ferritin and transferrin receptor provide the best approach to measuring the iron status of a population.[9]

The prevalence of iron deficiency anemia among participants in this study is far lower than the regional prevalence of 47.5%–67.6%.[17] A similar but relatively lower finding was reported by El Hioui et al., who found the prevalence of anemia among school-aged children to be 12.2%, and only about 20% (of the anemic children) were associated with iron deficiency, thus giving a prevalence of iron deficiency anemia to be 2.5%.[21] This was largely attributed to the study region, which had an abundance of fish, vegetables, fruits, and other cereals, which are all good sources of iron. These may also be the reason for low prevalence of iron deficiency anemia in this study because nomadic Fulani graze in the wild and have opportunities to consume fruits and vegetables.

Conversely, high prevalence rates of iron deficiency anemia were reported among settled school-aged children in Côte d'Ivoire, Kenya, and Port Harcourt as 25%, 30.4%, and 33.75%, respectively.[10],[25],[29] This was mostly attributable to poor dietary intake and parasitic infestation. The concomitant prevalence of low ferritin and high sTfR levels in this study is reflective of the early stage of iron depletion and possible role of inflammation. In addition, this is further corroborated by the absence of significant correlation between ferritin and sTfR levels.

A high sTFR level in the background of anemia and low prevalence of iron deficiency suggests that iron deficiency is not the only important cause of anemia in this population. Hence, other causes of anemia, which may be associated with high sTfR levels, such as hemoglobinopathies and combined nutritional deficiencies, are important possibilities. In additiion, it will be important to assess other noniron deficiency causes of microcytosis and/or hypochromia such as sideroblastic anemia, lead poisoning, and thalassemia in such populations. It is also worth noting that a significant number of West Africans have a silent α-thalassemia gene.[30]


  Conclusion Top


There is a high prevalence of anemia among nomadic Fulani children at Ladduga grazing reserve; however, iron deficiency is not the only cause of anemia.

Acknowledgment

We will like to acknowledge the management and staff of the National Commission for Nomadic Education for their support. Special appreciation goes to Dr. Umar Ardo, Mallam Lawal Boro, Alhaji Haruna Garba, and Mallam Mannir. Our appreciation goes to all personnel that helped in carrying out laboratory investigations conducted in the course of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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