The prevalence of 19.9% is significantly higher than reported by previous studies amongst the same age group in Saudi Arabia [5 – 7]. In our study both males and females showed almost equal prevalence of anemia (19.3% vs 21.2%), which is in contradiction with previous studies that have reported significantly higher prevalence amongst the females [5 -7, 19]. The International review study on anemia reported a prevalence of 10% among people aged >65 years, that increased to 40% among elderly aged >80 years [20]. We observed an overall increase of 6% in anemia among >60 years with respect to <60 years. Our sample had very few people aged > 80 years (n=4), hence, we are limited in commenting on the increase in this specific group.
The findings related to majority of anemic males in the older age category (> 60 years) can be explained through various mechanisms. It is proven that age leads to increase in pro-inflammatory cytokines, especially IL-6, which in turn inhibits the synthesis of erythropoietin, which may impair the erythroid progenitor cell proliferation, and interferes with iron metabolism [21, 22]. In addition, age-related inflammatory conditions lead to increased cytokine production, which stimulate the liver to release hepcidin, which in turn decreases intestinal absorpstion of iron and decreases the release of iron from macrophages [21]. There is also reason decreased responsiveness of the bone marrow erythroid precursors to stimulatory growth factors with advancing age that may contribute to higher prevalence of anemia among elderly males [22].
Diluted yogurt, Laban, is one of the most ancient, widely consumed, drink in the Arab world [23]. It belongs to the group of fermented food products, containing probiotics [24, 25]. Studies from Middles East, including Saudi Arabia have confirmed the presence of probiotics in yogurt and dairy drinks, including Laban [26, 27]. Probiotics, containing the Lactic Acid Bacteria (LAB) are known to have various beneficial effects including controlling and preventing gastrointestinal problems, allergies, cholesterol and regulating the immune functions [24 -28].
One of the bacilli, the Lactobacillus plantarum is found to assist in the iron absorption from the gut by maintaining acidic environment, acting as an anti-inflammatory agent [29] or by producing iron chelating ligands or by degrading the mineral complexing phytic acid from the food consumed, thus defining its role in preventing iron deficiency anemia [30]. However, there are contradictory findings related to the association between the two [31 – 35]. Interventional study found out that fermented food items increase the absorption of heam and non-heam iron in child-bearing aged women [31, 32]. However, other studies on children and women have failed to establish any positive association between LAB and the iron absorption [33 -35]. Whether the probiotics are important during each stage of life, or they are more health beneficial among the elderly needs to be investigated further. In addition, prospective, interventional study to observe the effect of Laban on the iron stores should be conducted.
The association between intake of red meat and anemia is well established [36]. Red meat is considered an important source for body iron. Heme iron is mainly available through meat intake and may be absorbed up to 50%, whereas non-heme iron is mainly available through fruits, vegetables, and dairy products (eggs, milk, butter, yogurt) and amounts are variable and depend upon enhancers and inhibitors for iron absorption [36]. Both white and red meat and citrus juices act as enhancers for iron absorption, whereas absorption is inhibited in presence of tea and coffee [36].
It is a general understanding that obesity is negatively associated with health. However, our findings are in support of a large-scale study conducted on Columbian reproductive age group women [37], that found overweight and obese women had lower prevalence of anemia as compared to normal weight. It is recommended that elderly people should consume high caloric diet as they are at risk of malnutrition [38]. In the older people, the daily recommended daily allowance (RDA) of proteins is same as for the younger 0.80 g/kg/day [39]. One explanation may be that despite being obese, they tend to consume diet, which is healthy, and rich in micronutrients, and hence they are at less risk of developing anemia.
Anemia can be both a diagnosis as well as a complication due to other diseases; hence, the earlier it is detected, the better the outcome [12, 13]. Fortunately, the majority of anemics in our study had mild anemia (Hb 11.0 – 12.9 mg/dL). Mild anemia, due to its trivial presentation, is usually ignored; however, complications are associated even with mild anemia [40]. Healthy people suffering from prolonged mild anemia are at increased risk of falls, hospitalizations and develop complications after surgical procedures [41]. Timely diagnosis of anemia reduces the financial burden as well. One single hemoglobin test from a private laboratory costs around 30-35 Saudi Riyal (US$ 9.45) (this is done free of cost in the newly established PHCC), which is quite less in comparison to the cost needed if someone develops severe anemia requiring blood transfusions. Apart from the health hazards, transfusions require a proper laboratory system; hence, health education and early screening for anemia in the elderly is important.
This is one of the first community-based surveys reporting the association between Laban intake and anemia in adults aged >50 years in Riyadh, Saudi Arabia. The number of participants in this age category was less compared to other; however, this distribution supports the actual age pyramid of Saudi Arabia, where a large population consist of children, adolescents and young adults compared to elderly. The findings of this study can be generalized to other urban/semi-urban areas of Saudi Arabia, as Riyadh is the capital and home to different social and ethical groups. Our study also had some limitations. We cannot comment on the type of anemia, as we failed to measure serum ferritin, vitamin B12 or Folate levels. The food frequency questionnaire was not validated hence lack of comparability of the results to those from other studies that have used standard instruments. The design was cross-sectional so that the temporal relation of Laban to anemia cannot be determined.
With increased aging in the Saudi population, the prevalence of anemia will is most likely to increase, causing a burden on the health system and the society. Hence, it is recommended that health education and early screening at the primary health care level should be made mandatory. Future prospective and interventional studies should explore the effect of Laban intake on improving the iron stores and hence hemoglobin among adults and elderly.