Anaemia among men was not given adequate attention due to a lower prevalence rate and a lesser number of affected populations compared to women and children4,6. This study observed that 12.6% of men in Malaysia had anaemia and the prevalence was three times higher among older men. A similar pattern of gradual increasing trends of anaemia with older age in previous studies with the starting point at the age of 50 years and above11,28. According to the WHO, the burden of anaemia was considered as moderate public health significance if the prevalence is between 20-39%. A previous local study noted that the trends of moderate public health significance among men started at the age of 50 years and this study found that it started a bit late at 60 years7,11. The improvement seen after four years is might due to improvement in chronic illness management in this country29. Prevalence of more than 40% is considered as a severe situation and need urgent action referring to anaemia in age group 75 years and above in this study7.
The prevalence of anaemia among men varies according to age as discussed above. It also varies according to geographical distribution, ethnicity, household income and diet practice19,30,31. The prevalence of anaemia in developed country such as the United States is much lower at 3.5% while for developing country such as India observed a prevalence of 23.2%6,32. A local study done recently reported that the prevalence of anaemia among men 35 to 70 years old was only 4.9% because this study used venous blood sampling and laboratory method for haemoglobin testing33.
The overall prevalence of anaemia among men via population-based survey was 14.3% (96%CI 13.3, 15.4) in 2015 and 12.6% (95%CI: 10.9,14.5) in 2020 which was more representative of the Malaysian men population24. However, this overall prevalence does not picture the burden of anaemia in specific group like the very old age group (75 years and above) of which obviously at the highest prevalence. By selecting the appropriate targeted group for anaemia estimates, it attracts the attention of policy maker to look into the problem seriously. Another example of targeted group for anaemia, person with diabetes. A local study observed prevalence of anaemia among men who had type 2 diabetes and chronic kidney disease was at 28.4% which required public health attention29. Older men who were underweight and having diabetes were noted to have a higher prevalence of anaemia. However, the pattern of prevalence of anaemia among younger men was nearly similar across all the socio-demographic factors, lifestyle factors and chronic diseases.
This study also investigated the factor associated with anaemia among men as the prevalence rate shows a huge difference between younger and older men. The possible reasons for these finding will be discussed according to the magnitude of association in the multivariable logistic regression model. The adjusted model indicated that age and the presence of diabetes were associated with anaemia among men after controlling for confounding variables. Although age had a significant interaction with diabetes mellitus, further analysis observed that older men with diabetes were associated with anaemia and the similar association was not found among younger men. The possible reason for this findings is due to the older men with diabetes may have diabetic nephropathy or renal anaemia and this condition might not present among younger men with diabetes29,34,35.
Besides diabetes mellitus, older person may presented with other chronic diseases such as hypertension, ischaemic heart disease, cerebrovascular disease and malignancy diseases36. Anaemia among older person also associated with dementia, disability and emotional disturbances which further impaired their activities of daily living and food intake37,38. However, this study only measured prevalence of diabetes mellitus, hypertension and hypercholesterolaemia which consistently higher among older men than younger men. The association of anaemia and hypertension was not found in this this study and the previous study39. Hypertension was included in the final model as the disease was prevalent among men in Malaysia and may related with cardiovascular disease. The presence of anaemia among those with cardiovascular problem worsened their health outcomes40,41.
Nonetheless, anaemia screening should be conducted regularly among older men as age is independently contributing to anaemia. Older age alone contributes to anaemia with the evidence of low erythropoietin level in the blood even though the older persons did not have chronic illnesses42,43. Haemoglobin level among healthy older person is physiologically decreasing with increasing age, however the cut-off point among older men remained at 13g/dL44. Older person tends to develop undernutrition due to lack of food, feeding problems, inappropriate diet or malabsorption30. A Higher prevalence of anaemia is expected in the place or country where poverty still a significant problem or the presence of political instability6.
The presence of anaemia among older person was associated with reduced survival rate and quality of life, however the impact was not observed among those aged below 60 years in Netherlands45. Among younger men, the association of diabetes and anaemia was not detected due to the small number of younger men who have diabetes or had developed diabetic nephropathy. This finding also explains that the cause of anaemia among younger men might be contributed by other causes such as acute blood loss, genetic disorder or nutritional deficiency. Young men usually have reversible cause of anaemia and lower prevalence of chronic illness.
Strengths and Limitations
This study used survey design methods, which has an advantage on Malaysian population representativeness. It utilised the online platform via an application using a tablet where the data was sent to the central team, immediately. It also used a validated point-of-care testing and well-trained data collectors were employed to collect data including medical staff for the clinical part. Screening for anaemia using a capillary blood sample may cause a little higher haemoglobin level which may result in underestimation. However, this point of care testing has been used widely for population-based screening and has been proven to provide a reliable estimation and comparable to the laboratory method6,21,22. In terms of data analysis, the multivariable analysis eliminates the confounding factor while highlighting the interaction issue enables the researcher to interpret findings according to specific a group.
The limitation of this study includes using the population-based data of the main objective is measuring the burden of non-communicable disease and its risk factors, hence much relevant information regarding anaemia was not collected. Information on the prevalence of chronic kidney disease, medication and supplement history intake, peptic ulcer disease, other tropical diseases, lead exposure in the work setting and dietary intake are important in anaemia prediction. Even though this is a population survey data, comparison of anaemia according to major ethnicities could not be made due to the small sample size of other ethnicities. The relationship of anaemia and underweight were not observed in this study due to the inadequate sample size among respondent who were underweight and a higher proportion of respondents who were overweight and obese. The survey was a cross-sectional design and had a limitation in a causal relationship.