Iron deficiency anemia (IDA) is the most prevalent micronutrient deficiency in the world, and a critical public health problem, especially in developing countries, particularly in children. Children attending school are particularly vulnerable due to their nutritional needs, which are greater than the body's normal requirements, recurrent infections, and bad dietary habits. The World Health Organization reports that almost 40% of the world's children suffer from anemia, and that iron deficiency is the biggest contributor to anemia. The impact of IDA on the physical growth, cognitive development, learning ability, school performance, and immune function of affected children has a negative impact on the quality of their life and their productivity in the future [1,2]. Malnutrition and poor socioeconomic situations play a key role in the burden of IDA in LMICs. Risk factors for anemia in school-aged children include an iron-deficient diet, limited food variety, intestinal parasite infections, and poor health services. Children of parents who are low-income tend to have diets that are low in nutrients, and thus have poor nutritional status, which increases their risk of iron deficiency. In addition, repeated infections and unhygienic conditions can further affect the body's capacity to absorb iron and exacerbate nutritional deficiencies [3,4]. Rather, nutritional status is one of the factors that influence the health of children and is evaluated by anthropometric indicators, including body mass index (BMI), height, and weight. Undernourished children have a higher risk of anemia due to inadequate intake of iron, vitamins, and proteins for hemoglobin production. Several studies have shown that underweight children with low BMI are more likely to be anemic. Nutrition inadequacy affects not only the health of the blood but also can cause retarded physical and mental growth [5]. Anemic school-going children may be fatigued, inattentive, weak, irritable, and have poor performance. Iron deficiency anemia, despite its high prevalence and effects, is often not diagnosed and treated in many developing countries. Delayed diagnosis and management are due to a lack of awareness by parents, poor nutrition education, and poor screening programs in schools. It is therefore important to identify anemia and associated nutrition issues as early as possible in order to minimize morbidity and enhance educational outcomes in children [6,7]. Malnutrition and micronutrient deficiencies are still significant problems in children in Pakistan. The prevalence of anemia in school-age children has been reported to be different in previous local studies, which could be attributed to variations in dietary habits, socioeconomic status, and health care services. But there is a lack of information on the relationship between IDA and the nutritional status of school-going children in many areas. This relationship is crucial to developing effective nutritional interventions and public health policies [8,9]. This study aimed to investigate the prevalence of iron deficiency anaemia in school-going children and to assess their correlation with the nutritional status. The results of this study could be used to create targeted screening programs, nutrition counseling programs, and preventive strategies that would benefit the health and learning of children [10].

Study Objectives

To find out the prevalence of Iron Deficiency Anemia (IDA) in school-going children and its correlation with nutritional status, BMI, and dietary habits in children aged 6-12 years

Study Design & Setting

A cross-sectional study was conducted by the Department of Pediatrics Unit II, Sandeman Provincial Hospital (SPH), Quetta, Pakistan, between 10 July 2025 and 10 Dec 2025. The study evaluated the prevalence of iron deficiency anemia (IDA) and the nutritional status of school-going children in selected public and private schools during the six-month study period.

Participants

100 school-going children aged 6-12 years were recruited by convenience sampling. Selected schools were attended by both male and female students. Informed consent was obtained from parents/guardians before participation. A structured form on Data Collection was used to obtain the demographic information, dietary habits, anthropometric indices, and laboratory investigations.

Sample Size Calculation

The World Health Organization sample size formula was used with an expected 35% rate of anemia, 95% confidence interval, and 5% margin of error to determine the number of 100 participants. The minimum sample size calculated was rounded up to 100 to ensure the reliability of the study and to provide a representative sample of the target population.

Inclusion Criteria

• Children aged 6–12 who attend school. Children aged 6-12 who are at school.
• Both male and female students
• Please note that we are not collecting personal data from children unless their parents have given their informed consent.
• The number of children attending selected schools during the study period.

Exclusion Criteria

• Children for whom there is a known hematological disorder.
• Children who have consumed iron supplements in the last three months. Children who have taken iron supplements in the last three months.
• Children with chronic systemic disease or an acute infectious disease.
• Children in cases of parental refusal.
• The diagnostic approach and treatment plan. The diagnostic process and the management strategy.

Diagnostic and Management Strategy

To diagnose iron deficiency anemia, hemoglobin and serum ferritin levels were measured. BMI (using the WHO growth charts) was used to assess nutritional status. Children diagnosed with anemia were referred for nutritional counselling and suitable medical management.

Statistical Analysis

The data is analyzed with SPSS software version 26. The quantitative variables were reported as mean ± SD, and the categorical variables were reported as frequencies and percentages. The association between anemia and nutritional status was determined using the chi-square test. Statistically significant p-values were considered as ≤ 0.05.

A total of 100 school-going children participated in the study, including 54 (54%) males and 46 (46%) females. The mean age of participants was 9.2 ± 1.8 years. Iron deficiency anemia was identified in 38 (38%) children, while 62 (62%) had normal hemoglobin levels. The prevalence of anemia was slightly higher among females compared to males; however, the difference was not statistically significant (p=0.08). Assessment of nutritional status showed that 23% of participants were undernourished according to BMI-for-age standards. Among children diagnosed with iron deficiency anemia, 60.5% were undernourished, whereas only 24.2% of non-anemic children had poor nutritional status. A statistically significant association was observed between iron deficiency anemia and poor nutritional status (p=0.003). The mean hemoglobin level among anemic children was 9.8 ± 1.1 g/dL compared to 12.4 ± 0.9 g/dL among non-anemic participants. Children with low dietary intake of iron-rich foods such as meat, green vegetables, and fruits demonstrated a higher frequency of anemia. Furthermore, children belonging to low socioeconomic families had comparatively greater prevalence of anemia than those from middle-income households. The study findings suggest that inadequate nutrition, poor dietary habits, and low BMI are major contributing factors associated with iron deficiency anemia among school-going children.

Intervention Outcome

Children diagnosed with iron deficiency anemia were provided with nutritional counselling and referred for iron supplementation. A post-implementation assessment demonstrated that most individuals had improved with dietary awareness and hemoglobin levels.

Table 1: Demographic Characteristics of Study Participants (n=100)

Table 1 demonstrates the demographic distribution of school-going children included in the study. The majority of participants were males (54%), with a mean age of 9.2 ± 1.8 years.

Table 2: Prevalence of Iron Deficiency Anemia Among Participants

Table 2 shows the prevalence of iron deficiency anemia among study participants. Overall, 38% of children were diagnosed with anemia, with significantly lower mean hemoglobin levels compared to non-anemic children.

Table 3: Association Between Iron Deficiency Anemia and Nutritional Status

Table 3 illustrates the association between iron deficiency anemia and nutritional status. Poor nutritional status was significantly more common among anemic children compared to non-anemic participants (p=0.003).

Table 4: Dietary Habits and Prevalence of Iron Deficiency Anemia

Table 4 presents the relationship between dietary iron intake and iron deficiency anemia. Children with inadequate intake of iron-rich foods showed significantly higher prevalence of anemia compared to children with adequate dietary intake (p=0.001).

The present study showed that iron deficiency anemia (IDA) is very common among school-going children and is significantly related to poor nutritional status. Out of 100 enrolled children, 38% were diagnosed with iron deficiency anemia, and the prevalence of anemia was significantly higher among the undernourished children as compared to the children with normal nutritional status. The results underline the ongoing problem of micronutrient deficiencies in school-aged children in developing countries and the need for nutritional screening and early action [11,12].The high prevalence of IDA found in this study is similar to recent regional and international studies. A study by Rahman et al. found that the prevalence of anemia among school-aged children was about 35%, whereas Ahmed et al. found the prevalence to be greater than 40% in the poor population. Similar conclusions were reached by Bansal et al.who found nutritional deficiencies and lack of dietary diversity to be the major causes of anemia in children. These similar prevalences are an expression of how iron deficiency anemia is still a public health problem despite the continuous nutrition programs and awareness creation [13,14]. We observed that nutritional status was significantly related to anaemia, with 60.5% of the children with anaemia being undernourished. This is in line with the recent studies done in South Asian populations. Khan et al. have shown that children with low BMI were significantly at risk of developing IDA compared to well-nourished children. Similarly, Sharma et al. reported that undernutrition has a negative impact on iron metabolism and hemoglobin synthesis, which leads to an increased predisposition to anemia. The relationship might be due to poor consumption of iron-rich foods, protein deficiency, or insufficient caloric intake [15,16].The mean hemoglobin level of the anemic children in the present study was 9.8 ± 1.1 g/dL, which is similar to the mean level of hemoglobin observed by Ali et al. where they found that the mean Hb level of anemic school children was below 10 g/dL. Patel et al. made similar findings, reporting that the hemoglobin concentrations were also lower and there were higher nutritional deficiencies among children in socioeconomically deprived families. Anemia is prevalent among people with low socioeconomic status due to limited access to a balanced diet, health care facilities, and nutritional education [17,18]. There was a slightly higher prevalence of anemia in female students than male students in the current study, but the difference was not statistically significant. Similar trends were pointed out by Gupta et al.who proposed the possibility of relatively poorer nutritional intake in female children and higher physiological requirements for iron in these children. However, a few studies have reported no significant difference between sexes in the prevalence of anemia, suggesting that besides gender, dietary practices and socio-economic factors can be more important [19]. The present study also highlighted that insufficient consumption of iron-rich food was significantly related to anaemia. The prevalence of Iron Deficiency Anemia was higher among children who consumed less green vegetables, fruits, meat products, and fortified foods. Iron Deficiency Anemia was more prevalent among children who consumed less green vegetables/fruits/fortified foods/meat products. Poor dietary diversity was also found to be one of the most significant factors associated with anemia among school-going children by Hussain et al. Furthermore, parasitic infections and recurrent illnesses may further compromise nutrient absorption and aggravate nutritional deficiencies [20]. The results of this study are relevant to public health. Improper nutrition can significantly impact anemia levels in children, and several initiatives can help mitigate this impact, including school-based nutritional screening, iron supplementation, deworming campaigns, and dietary education. A study by Verma et al. found that early nutritional interventions and school health programmes had a significant effect on the level of haemoglobin as well as their academic performance in children with anaemia. Incorporating nutrition monitoring into school health programmes can thus be of benefit for early detection and proper handling of IDA.

Limitations

The study was constrained by a small sample size and a single-center design, and findings might not be generalizable to other centers. Assessment of dietary intake relied upon self-reported information that may have introduced recall bias. Further, other forms of anemia, including those due to parasites and vitamin deficiencies, were not well studied,

School children had a high prevalence of iron deficiency anemia, and there was a strong relationship between iron deficiency anemia and nutrition and dietary intake. Early screening and nutrition counseling and school-based intervention programs are crucial to enhance the physical and academic growth of children, lower the malnutrition rate, and improve their hemoglobin level.

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