Prevalence of anemia of varying severity, geographic variations, and association with metabolic factors among women of reproductive age in China: a nationwide, population-based study
Heling Bao1, Yuanyuan Huang1, Yi Sun1, Yunli Chen1, Yan Luo1, Liping Yan1, Sailimai Man2,3,4,5, Canqing Yu2,4,5,6, Jun Lv2,4,5,6, Meili Ge7, Linhong Wang8, Liming Li2,4,5,6(), Bo Wang3,4,6(), Hui Liu1(), Xiaoxi Liu1()
. Institute of Medical Information, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100020, China . Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing 100191, China . Meinian Institute of Health, Beijing 100044, China . Peking University Health Science Center Meinian Public Health Institute, Beijing 100191, China . Key Laboratory of Epidemiology of Major Diseases (Peking University), Ministry of Education, Beijing 100191, China . Peking University Center for Public Health and Epidemic Preparedness & Response, Beijing 100191, China . Anaemia Diagnosis and Treatment Center, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin 300052, China . National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 100050, China
To investigate the epidemiological characteristics of anemia of varying severity among women of reproductive age, we conducted a nationwide, cross-sectional study between January 1, 2019 and December 31, 2019, including 4 184 547 nonpregnant women aged 18–49 years from all 31 provinces in the mainland of China. Anemia was defined as having hemoglobin concentration < 120.0 g/L and categorized as mild, moderate, and severe. Multivariate logistic models with cluster effect were used to explore the association of anemia and metabolic risk factors. The standardized prevalence of anemia and moderate and worse anemia among women of reproductive age in China was 15.8% (95% CI 15.1%–16.6%) and 6.6% (6.3%–7.0%), respectively. The prevalence of anemia and the proportion of moderate and worse anemia significantly increased with age. We also observed great geographic variations in the prevalence of anemia, with a high likelihood in south, central, and northwest China. Moderate and/or severe anemia was positively associated with overweight and obesity, diabetes, and impaired kidney function. In conclusion, anemia remains a significant challenge for women of reproductive age in China. Geographic variations and metabolic risk factors should be considered in the comprehensive and targeting strategy for anemia reduction.
Corresponding Author(s):
Liming Li,Bo Wang,Hui Liu,Xiaoxi Liu
Just Accepted Date: 04 June 2024Online First Date: 31 July 2024Issue Date: 29 October 2024
Cite this article:
Heling Bao,Yuanyuan Huang,Yi Sun, et al. Prevalence of anemia of varying severity, geographic variations, and association with metabolic factors among women of reproductive age in China: a nationwide, population-based study[J]. Front. Med.,
2024, 18(5): 850-861.
Tab.1 Characteristics of participants and anemic patients stratified by severity
Fig.1 Prevalence of anemia among women of reproductive age in China stratified by age and severity. (A) Crude and weighted prevalence of anemia, overall and by severity. (B) Age-specific prevalence of overall, mild anemia, and moderate and worse anemia. (C) Proportion of anemia of varying severity. (D) Proportion of anemia of varying severity stratified by age. Error bars represent the 95% CI. Moderate and worse includes moderate and severe anemia.
Anemia (95% CI)
Severity of anemia (95% CI)
Mild
Moderate
Severe
Moderate and worse
Overall
15.8 (15.1–16.6)
9.2 (8.8–9.7)
6.1 (5.8–6.5)
0.44 (0.41–0.48)
6.6 (6.3–7.0)
Body mass index
< 18.5
14.2 (13.4–15.0)
9.4 (8.8–9.9)
4.6 (4.3–4.9)
0.21 (0.18–0.24)
4.8 (4.5–5.2)
18.5–23.9
16.3 (15.5–17.1)
9.8 (9.3–10.3)
6.1 (5.8–6.5)
0.42 (0.39–0.46)
6.6 (6.2–7.0)
24.0–27.9
15.7 (15.0–16.3)
8.4 (8.0–8.8)
6.7 (6.4–7.0)
0.56 (0.52–0.61)
7.3 (6.9–7.7)
≥ 28.0
13.7 (13.0–14.3) b
7.2 (6.8–7.5) b
6.0 (5.7–6.3) b
0.52 (0.47–0.57) b
6.5 (6.2–6.9) b
Hypertension
No
15.9 (15.1–16.6)
9.4 (8.9–9.8)
6.1 (5.7–6.4)
0.44 (0.40–0.48)
6.5 (6.2–6.9)
Yes
15.2 (14.6–15.7) a
7.7 (7.4–8.0) b
7.0 (6.7–7.3) b
0.50 (0.47–0.54) b
7.5 (7.2–7.9) b
Diabetes
No
15.9 (15.1–16.6)
9.3 (8.8–9.7)
6.1 (5.8–6.5)
0.44 (0.41–0.48)
6.6 (6.3–7.0)
Yes
11.6 (11.1–12.2) b
5.4 (5.1–5.8) b
5.3 (5.0–5.6) b
0.53 (0.45–0.61) a
5.9 (5.5–6.2) b
High total cholesterol
No
17.0 (16.2–17.8)
9.8 (9.3–10.2)
6.7 (6.3–7.0)
0.53 (0.49–0.58)
7.2 (6.8–7.6)
Yes
11.5 (10.9–12.1) b
7.3 (6.9–7.7) b
4.1 (3.9–4.3) b
0.10 (0.09–0.12) b
4.2 (4.0–4.4) b
High triglyceride
No
16.3 (15.6–17.1)
9.5 (9.1–10.0)
6.3 (6.0–6.6)
0.46 (0.43–0.50)
6.8 (6.4–7.1)
Yes
12.4 (11.7–13.0) b
7.1 (6.6–7.6) b
4.9 (4.7–5.2) b
0.31 (0.29–0.34) b
5.2 (5.0–5.5) b
Hyperuricemia
No
16.4 (15.7–17.1)
9.5 (9.1–10.0)
6.4 (6.1–6.8)
0.47 (0.43–0.51)
6.9 (6.5–7.3)
Yes
9.3 (8.7–10.0) b
6.2 (5.7–6.7) b
3.0 (2.8–3.2) b
0.16 (0.14–0.18) b
3.1 (2.9–3.4) b
History of cesarean delivery
No
15.7 (14.9–16.4)
9.2 (8.7–9.6)
6.1 (5.7–6.4)
0.44 (0.40–0.47)
6.5 (6.2–6.9)
Yes
18.3 (17.0–19.6) b
10.4 (9.7–11.2) a
7.3 (6.7–7.9) a
0.55 (0.49–0.62) b
7.9 (7.3–8.6) b
Impaired kidney function
No
15.8 (15.1–16.5)
9.2 (8.8–9.7)
6.1 (5.8–6.5)
0.44 (0.41–0.48)
6.6 (6.2–6.9)
Yes
31.9 (24.3–39.4) b
20.7 (9.4–32.1) a
9.9 (4.7–15.1)
1.22 (0.47–1.97) a
11.1 (5.3–17.0)
Tab.2 Prevalence of anemia among women of reproductive age in China
Fig.2 Geographic variations in the standardized prevalence of anemia of varying severity among women of reproductive age and correlation with urbanization and per capita annual consumption of main food. The top panels show the provincial prevalence of anemia of varying severity among (A) all women, (B) women aged 18–34 years, and (C) women aged 35–49 years. Error bars represent the 95% CI of anemia. Vertical dashed lines indicate the threshold (20%) of moderate public health significance recommended by WHO. The middle panels present the variations by seven geographic regions among (D) all women, (E) women aged 18–34 years, and (F) women aged 35–49 years. The bottom panels show the ecological correlation between anemia and (G) urbanization and the proportion of per capita annual consumption of main food, including (H) meat, fish, and egg, (I) vegetables and fruits, (J) cereal, and (K) sugar. Linear regression was used to estimate the relationship coefficients.
Independent variables
Anemia
Moderate and worse anemia
OR (95% CI)
P value
OR (95% CI)
P value
Age (per 5 years)
1.20 (1.19–1.21)
< 0.0001
1.31 (1.29–1.31)
< 0.0001
Body mass index
< 18.5
0.99 (0.97–1.00)
0.07
0.92 (0.90–0.94)
< 0.0001
18.5–23.9
Reference
Reference
24.0–27.9
0.93 (0.92–0.94)
< 0.0001
1.02 (1.00–1.04)
0.04
≥ 28.0
0.91 (0.88–0.94)
< 0.0001
1.04 (1.01–1.07)
0.02
Hypertension
No
Reference
Reference
Yes
0.89 (0.87–0.91)
< 0.0001
0.96 (0.94–0.98)
0.0001
Diabetes
No
Reference
Reference
Yes
0.75 (0.72–0.79)
< 0.0001
0.82 (0.79–0.85)
< 0.0001
High total cholesterol
No
Reference
Reference
Yes
0.59 (0.57–0.61)
< 0.0001
0.47 (0.46–0.49)
< 0.0001
High triglyceride
No
Reference
Reference
Yes
0.78 (0.75–0.82)
< 0.0001
0.75 (0.73–0.77)
< 0.0001
Hyperuricemia
No
Reference
Reference
Yes
0.62 (0.59–0.64)
< 0.0001
0.51 (0.48–0.53)
< 0.0001
Impaired kidney function
No
Reference
Reference
Yes
2.38 (1.76–3.22)
< 0.0001
2.00 (1.02–3.95)
0.045
History of cesarean delivery
No
Reference
Reference
Yes
1.16 (1.09–1.23)
< 0.0001
1.17 (1.10–1.25)
< 0.0001
Tab.3 Multivariable-adjusted odds ratio for anemia among women of reproductive age in China
Fig.3 Difference in the nonlinear associations of (A) anemia, (B) mild anemia, (C) moderate anemia, and (D) severe anemia with BMI. Lines represent odd ratios estimated from a logistic regression between anemia and BMI, adjusted for hypertension, diabetes, high total cholesterol, high triglyceride, hyperuricemia, impaired kidney function, city-level per capita GDP, province-level unemployment, and province-level education. BMI was fitted as a four-knot restricted cubic spline as the 5th, 35th, 65th, and 95th percentiles to allow for nonlinearity. P values for overall association and nonlinearity were less than 0.0001 for all outcomes. Vertical lines represent BMI category thresholds of 18.5 kg/m2 (underweight to healthy), 24 kg/m2 (healthy weight to overweight), and 28 kg/m2 (overweight to obese).
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