Community awareness of association between black tea consumption and iron deficiency anemia

ABSTRACT

Background:

Iron deficiency anemia (IDA) is a prevalent issue in public health that impacts individuals globally, regardless of age. Several risk factors have been documented to be linked to a higher prevalence of IDA, including the drinking of black tea.

Aim:

This study aimed to evaluate the community’s awareness of the relationship between black tea consumption and iron deficiency anemia in Riyadh, Saudi Arabia.

Subject and Methods:

This cross-sectional study was conducted among the adult population living in Riyadh, Saudi Arabia. A self-administered questionnaire was distributed among participants during community meetings, local events, and social media campaigns. The questionnaire includes socio-demographic characteristics and a 24-item questionnaire to assess awareness about black tea consumption and iron deficiency anemia.

Results:

Of the 337 participants, 74.2% were females, and 56.1% were between 18 and 24 years old. 49.3% were drinking 1–2 cups of black tea per day. Headache, dizziness, or lightheadedness (77.4%) and severe fatigue (75.7%) were recognized as the most common symptoms of IDA. 32.6% of the respondents regarded having a good level of awareness of the association between black tea consumption and IDA. Female gender, medical education major, and non-black tea drinkers were recognized as the significant factors of increased awareness about black tea consumption and IDA associations.

Conclusion:

There was satisfactory awareness of the association between black tea consumption and IDA among the general population. However, the male gender, respondents with non-medical majors, and those who drink 3 or more cups of black tea per day were more likely to exhibit a lack of awareness about black tea consumption and IDA associations. Further larger studies are needed to establish the awareness of the association between black tea consumption and IDA in our region.

Background

Iron deficiency Anemia (IDA) is a prevalent issue in public health. impacting individuals globally, regardless of age. Several risk factors have been documented to be linked to a higher prevalence of IDA, including the drinking of black tea.[1]

Anemia is defined by the WHO as blood Hb levels below 130 g/L for men and 120 g/L for women, with serum ferritin being less than 30 ug/L in cases of isolated iron deficiency.[2] One of the biggest issues impacting people worldwide is poor iron status, which is caused by a prolonged negative iron balance.[3]

Studies indicate that between 30% and 56% of Saudi Arabia’s population suffers from iron deficiency anemia.[4,5] Non-heme iron absorption, which makes up 70%–90% of dietary iron, is strongly inhibited by a variety of substances found in black tea, including phytate and tannin.[6]

Since black tea is widely consumed in Saudi Arabia and is seen as a component of Saudi culture,

The Food and Agriculture Organization (FAO) of the United Nations reports that, with a growth rate of 3.0% in 2018, Saudi Arabia was among the nations that had increased their consumption of black tea in the last decade.[3] The significance of this study is highlighted.

Developing focused interventions and strategies to address iron deficiency anemia (IDA) requires a comprehensive understanding of community awareness regarding the relationship between black tea consumption and iron status, particularly within the Saudi Arabian context.

By exploring individuals’ knowledge and perceptions, this study generates insights essential for healthcare practitioners and public health officials. For practitioners, such insights can inform targeted educational campaigns, enabling them to effectively address existing gaps in nutritional knowledge, especially in populations at elevated risk for IDA. For patients and the broader community, increased awareness and enhanced knowledge provide a practical foundation for making informed dietary decisions, potentially reducing risk factors associated with IDA and improving overall health outcomes. Consequently, this study contributes valuable data that can guide public health initiatives, dietary counseling practices, and preventive strategies aimed at mitigating iron deficiency anemia in the Saudi Arabian population.

Previous research provides essential insights into the association between black tea consumption and iron deficiency anemia (IDA) across various contexts. Elmaghraby et al.[3] (2021) conducted a cross-sectional study in the Al Ahsa region, Saudi Arabia, assessing community awareness about the relationship between black tea and IDA. They found a significant correlation between awareness levels and demographic factors such as age and educational background. However, their study was limited to participants able to access the internet, potentially affecting the representativeness of their findings.

Contrastingly, Nyakundi et al.[7] (2024) found a clear association between tea consumption patterns and iron deficiency among women of childbearing age in Kenya. Their results demonstrated that increased tea intake correlated with lower serum ferritin levels, reinforcing the importance of consumption patterns influencing iron status.

A similar theme emerged from research by Jamnok et al.[8] (2020), who investigated anemia and iron deficiency prevalence among reproductive-age women in Northeast Thailand. They found a notable prevalence of anemia (28%) and identified specific dietary habits and chronic conditions, including thalassemia, as contributing factors. These findings underscore dietary behaviors and underlying health conditions as critical determinants in iron deficiency prevalence.

Finally, Machmud et al.[9] (2019) explored tea consumption’s specific impact on iron status among pregnant women in Indonesia. Their study highlighted a clear relationship between higher tannin levels in tea and reduced serum ferritin, thereby implicating tannin concentration as a critical mediator of iron absorption.

Collectively, these studies underscore the nuanced relationship between black tea consumption and IDA, influenced by diverse factors including regional dietary habits, socio-economic status, demographic characteristics, and tea preparation methods. These nuances reinforce the importance of localized research and targeted educational interventions to address specific community needs effectively.

This study aims to assess community awareness of the association between the consumption of black tea and iron-deficiency anemia. Ethical approval was obtained from the Institutional Review Board (IRB) of Imam Mohammad Ibn Saud Islamic University, Saudi Arabia. The approval number is HAPO-01-R-0011, and the date of approval is June 20, 2024.

Study Design and Setting

A cross-sectional descriptive study was conducted in Riyadh, Saudi Arabia, to evaluate the awareness among adult residents regarding the relationship between black tea consumption and iron deficiency anemia. Data collection was performed using a self-administered online questionnaire.

Sampling Technique and Participants

A sample size of 385 participants was determined based on the total Riyadh population in 2023 (8,591,748), using a 95% confidence level and a 5% margin of error. The inclusion criteria involved individuals aged 18 years and older, residing in the Riyadh region, and consuming black tea at least once per week. Exclusion criteria included individuals diagnosed with conditions that independently affect iron absorption (e.g. celiac disease, Crohn’s disease), those receiving treatment for iron deficiency anemia or taking iron supplements, and pregnant or lactating women. Eligible participants completed the survey and were included in the final analysis.

Study Measurements

The questionnaire used in this study was designed following a literature review and adapted to meet the study’s objectives and target population. It included demographic data such as gender, age, and education level, as well as questions related to dietary habits and black tea consumption. Awareness of the association between black tea and iron deficiency anemia was evaluated using a series of structured questions, as outlined in the questionnaire criteria.

Questionnaire Criteria

The awareness of the association between black tea consumption and iron deficiency anemia has been assessed using a 24-item questionnaire, with the correct answer for each question being identified and coded with 1, while the incorrect answer being coded with 0. The total awareness score has been calculated by adding all 24 items. Scores ranging from 1 to 24 have been achieved. The higher the score, the higher the awareness of black tea consumption and iron deficiency anemia associations. By using 50% and 75% as cutoff points to determine the level of awareness, participants were categorized as having poor awareness if the score was below 50%, 75% to 75% were moderate, and above 75% were good knowledge levels.

Statistical analysis

The data were presented by numbers and percentages for all categorical variables, while mean and standard deviation were used to elaborate on continuous variables. The awareness score was compared with the socio-demographic characteristics of participants by using the Mann–Whitney Z-test and the Kruskal–Wallis H-test. The normality test was performed using the Kolmogorov-Smirnov test. Based on the plot, the awareness score follows a non-normal distribution. Therefore, the non-parametric tests were applied. Further, post hoc analysis was performed to determine the multiple mean differences between the awareness score and number of cups of black tea consumed daily by using the Dunn–Bonferroni test. Statistical significance was set to a P < 0.05 level. All data analyses were performed using the Statistical Packages for Social Sciences (SPSS) version 26 Armonk, New York, IBM Corporation.

Results

Three hundred and thirty-seven out of three hundred and eighty-five participants met the inclusion criteria (response rate: 87.5%). Table 1 presents the socio-demographic characteristics of participants. Approximately 56.1% were between 18 and 24 years old. Females (74.2%) were predominantly higher than males (25.8%). Participants who were bachelor’s degree holders constituted 68.8%, and those with non-medical majors were 68.2%. Nearly half (49.3%) consumed 1–2 cups of black tea daily [Figure 1], and 34.7% usually drank black tea shortly before or after the meal [Figure 2].

Table 1.

Socio-demographic characteristics of participants (n=337)

Study variables	n (%)
Age group
• 18–24 years	189 (56.1%)
• 25–39 years	66 (19.6%)
• 40–59 years	63 (18.7%)
• ≥60 years	19 (05.6%)
Gender
• Male	87 (25.8%)
• Female	250 (74.2%)
Educational level
• Intermediate	04 (01.2%)
• Secondary	62 (18.4%)
• University education	232 (68.8%)
• Postgraduate degree	39 (11.6%)
Type of education major
• Medical	107 (31.8%)
• Non-medical	230 (68.2%)
Number of cups of black tea consumed daily
• None	113 (33.5%)
• 1–2	166 (49.3%)
• 3–4	40 (11.9%)
• >4	18 (05.3%)
Black tea drinking habit
• None	113 (33.5%)
• Shortly before and after the meal	117 (34.7%)
• With meals	45 (13.4%)
• 2–3 hours after a meal	62 (18.4%)

Figure 1.

Number of cups of black tea consumed daily

Figure 2.

Black tea drinking habit

Regarding the assessment of the awareness about black tea consumption and IDA [Table 2], it was observed that 73.3% were able to identify the correct definitions of IDA. Also, 92.6%, 59.1%, and 47.8% were correct that iron deficiency, sickle, and hemolytic anemia were the most common types of anemia. 69.1% and 51.6% were correct that IDA is more common and more dangerous in children and pregnant women. The top three most common symptoms and diagnoses of IDA were headaches, dizziness or lightheadedness (77.4%), severe fatigue (75.7%), and pale skin (74.2%), while elevated blood pressure showed the least (9.8%). Approximately 70.6% knew IDA was the most common type of anemia, while 64.4% believed drinking black tea and a meal might decrease iron absorption. 41.8% believed there would be a high percentage decrease in iron absorption when drinking black tea with a meal. Nearly all (96.4%) were aware that liver, red meat, egg yolk, and lentils are foods containing a considerable amount of iron, while a similar proportion (91.4%) knew that milk, black tea, coffee, and cheese were foods that may decrease iron absorption. About half (53.4%) believed that citrus fruits are foods that may increase iron absorption, whereas 62.6% thought that two or three hours after the meal is the best time for drinking black tea. Based on the above awareness items, the overall mean awareness score was 16.5 (SD 3.72), with poor, moderate, and good knowledge constituting 10.7%, 56.7%, and 32.6%, respectively [Figure 3].

Table 2.

Assessment of awareness about black tea consumption and iron-deficiency anemia (n=337)

Awareness items	n (%)
Iron deficiency anemia can be defined as [Decreased red blood cell production due to low iron stores in the body]	247 (73.3%)
1. Which of the following is a type of anemia
2. Diabetes [no]	332 (98.5%)
3. Hypertension [no]	329 (97.6%)
4. Hemolytic anemia [yes]	161 (47.8%)
5. Sickle anemia [yes]	199 (59.1%)
6. Iron deficiency anemia [yes]	312 (92.6%)
7. Iron-deficiency Anemia is more common [Pregnant women and Children]	174 (51.6%)
8. Iron-deficiency anemia is more dangerous in Pregnant women and Children	233 (69.1%)
Symptoms and diagnosis of iron deficiency anemia
9. Hyperglycemia [no]	317 (94.1%)
10. Headache, dizziness, or lightheadedness [yes]	261 (77.4%)
11. Severe fatigue [yes]	255 (75.7%)
12. Pale skin [yes]	250 (74.2%)
13. Low hemoglobin level [yes]	240 (71.2%)
14. Cold hands and feet [yes]	239 (70.9%)
15. Nail strikes [yes]	199 (59.1%)
16. Chest pain, palpitations [yes]	156 (46.3%)
17. Elevated blood pressure [yes]	33 (09.8%)
18. Iron deficiency anemia (IDA) is the most common type of anemia [yes]	238 (70.6%)
19. In your opinion, drinking black tea with a meal may decrease iron absorption [yes]	217 (64.4%)
20. In your opinion, drinking black tea with a meal can decrease iron absorption by [High percent]	141 (41.8%)
21. Which of the following foods contain a considerable amount of iron [liver, red meat, egg yolk, lentils]	325 (96.4%)
22. Which of the following foods may decrease iron absorption? [milk, black tea, coffee, cheese]	308 (91.4%)
23. Which of the following foods may increase iron absorption [Citrus fruits]	180 (53.4%)
24. In your opinion, the best time for drinking black tea is [Two or three hours after the meal]	211 (62.6%)
Total awareness score (mean±SD)	16.5±3.72
Level of awareness
• Poor	36 (10.7%)
• Moderate	191 (56.7%)
• Good	110 (32.6%)

Figure 3.

Level of awareness toward the association between black tea and iron-deficiency anemia

Examining the association between the awareness and the socio-demographic characteristics of participants found that higher awareness scores were associated with being female (Z = 4.174; P < 0.001), having a medical major (Z = 9.018; P < 0.001), and being a non-black tea drinker (H = 4.445; P = 0.035). No significant differences were observed between the awareness scores about age group, education, and black tea drinking habit (P > 0.05) [Table 3].

Table 3.

Association between awareness and the socio-demographic characteristics of participants (n=337)

Factor	Awareness Score (24) Mean±SD	Z-test	P §
Age group
• <25 years	16.7±3.75	1.347	0.178
• ≥25 years	16.2±3.68
Gender
• Male	15.0±3.67	4.174	<0.001**
• Female	17.0±3.60
Educational level
• Secondary or below	16.3±3.73	0.604	0.546
• University degree or higher	16.5±3.73
Type of education major
• Medical	19.0±3.13	9.018	<0.001**
• Non-medical	15.3±3.67
Number of cups of black tea consumed daily‡
• None	17.1±3.94	4.445	0.035**
• 1–2	16.5±3.58
• ≥3	15.2±3.42
Black tea drinking habit‡
• None	17.1±3.94	0.222	0.895
• Shortly before and after the meal	16.2±3.76
• With meals	15.9±3.28
• 2–3 hours after a meal	16.3±3.48

^§P value has been calculated using the Mann–Whitney Z-test. ^‡P value has been calculated using the Kruskal–Wallis H-test. **Significant at P<0.05 level

In post hoc analysis to determine the multiple mean differences of awareness score in terms of the number of cups of black team consumed per day, we found that there was a statistically significant difference in the mean score between participants who were non-black tea drinkers versus those who drink ≥3 black tea daily (P = 0.007) [Table 4].

Table 4.

Multiple mean differences of awareness score in relation to the number of cups of black tea consumed daily (n=337)

(I) # of Cups	(J) # of Cups	Mean Difference (I−J)	Std. Error	Sig.	95% Confidence Interval
					Lower Bound	Upper Bound
None	1–2	0.54068	0.44901	0.688	-0.5397	1.6210
	≥3	1.82942**	0.59470	0.007	0.3985	3.2603
1-2	None	−0.54068	0.44901	0.688	−1.6210	0.5397
	≥3	1.28874	0.56157	0.067	−0.0625	2.6399
≥3	None	−1.82942**	0.59470	0.007	−3.2603	−0.3985
	1–2	−1.28874	0.56157	0.067	−2.6399	0.0625

Post-hoc analysis has been conducted using the Dunn–Bonferroni test. **The mean difference is significant at P<0.05 level

Discussion

This study explores the community’s awareness of the possible link between black tea consumption and iron deficiency anemia. This topic could be an important contribution to the literature, as it could raise the community’s awareness, promote nutritional balance, and improve public health outcomes. Studying the effect of black tea on iron status can also provide insights into dietary patterns and their health implications. It can help in understanding how common dietary habits may lead to the development of deficiencies or other nutritional issues. Hence, the findings of this study are critical, given the implications of the outcomes for public health issues.

Level of awareness

The community’s awareness of black tea consumption and the IDA association achieved better than desired. Based on the given criteria, nearly 90 percent of the population attained moderate to good awareness levels (mean score of 16.5 out of 24 points). Only 10.7% are considered low. Consistent with our reports, several studies documented moderate to good awareness of IDA and its association with drinking black tea.[3,10,11] In support of previous reports, Khatimah et al.[12] (2023) reported a significant improvement in knowledge after educational sessions about anemia. In contrast, Aboud et al.[5] (2019) indicated that more than two-thirds of pregnant women had poor knowledge about IDA, which was consistent with the study published by Asiko (2015).[13] These differences could mainly be due to study focus, population diversity, and regional settings. A multi-faceted approach that includes health education, behavioral change strategy, and collaboration with healthcare professionals were some of the strategies that could enhance awareness regarding black tea consumption and IDA association among the population in the community.

Significant factor of awareness

Increased awareness was associated with being female and having a medical education major. Potential reasons for this effect include women tend to have better awareness than men because women are generally at higher risk of IDA, they have a greater role in dietary and nutritional plans in their family, and they are more active in public health campaigns, while participants with medical education major may have exhibited better awareness due to educational background, exposure to research and clinical practice, and access to reliable information. This is inconsistent with the study of Balaji et al.[14] (2022), suggesting that educated participants demonstrated better knowledge and awareness about IDA than participants with lower education. Corroborating these reports, Kakabra and Saeed[11] (2024) found that female knowledge positively correlated with the parents’ educational level. However, they found no significant association between knowledge and other socio-demographic factors. In our study, age and education showed no relevant association with awareness (P > 0.05), which did not coincide with previous reports. Population diversity, cultural and regional differences, study design, and methodology were some of the factors that might influence these variations.

Awareness about IDA

Our results suggest that most respondents were aware of the basic facts of IDA. For instance, nearly three-quarters knew the correct definition of IDA, and a great proportion of the population recognized IDA, sickle anemia, and hemolytic anemia as the most prominent types of anemia, while the majority disagreed that diabetes and hypertension were also types of anemia. Further, over half of the sample population understood that pregnant women and children were more susceptible to IDA. In addition, more than seventy percent of participants were able to recognize the most common symptoms associated with IDA, including headache, dizziness or lightheadedness, severe fatigue, pale skin, low hemoglobin level, and cold hands and feet, except for elevated blood pressure, where participants had low ratings (9.8%). This is almost consistent with the study of Shehata et al.[10] (2020), suggesting that over 70% of the respondents had heard of anemia, and approximately 89% believed that anemia is a health problem. Additionally, 69% indicated that an anemic person had a decreased hemoglobin level. Supporting these reports, Al-alimi et al.[15] (2018) noted the potential risk factors for iron deficiency include recent blood donation and moderate to high levels of blood loss during menstruation, while a study done by Sadiq et al.[16] (2024) reported significant variations of hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin levels between tea-drinkers and non-tea-drinkers in women of reproductive age.

Awareness about food and nutrients associated with anemia

Just like a high awareness of IDA, the general population also showed a better understanding of food and nutrients influencing anemia. For example, more than ninety percent of individuals knew the foods that contain a considerable amount of iron (i.e. liver, red meat, egg yolk, etc.) and the foods that decrease iron absorption (e.g. milk, black tea, coffee, etc.). They also knew that drinking black tea with a meal may decrease iron absorption. Nonetheless, about two-thirds suggested the best time to drink black tea was two to three hours after the meal. This agrees with the previous reports of Aedh et al.[4] (2019), indicating that frequent consumption of vegetables and white meat and drinking tea or coffee did not significantly influence anemia. However, a study conducted by Machmud et al.[9] (2019) revealed that decreased eating of food containing heme, tannin consumption, parity, and the time since the last pregnancy were the factors that influenced IDA. On the contrary, Adjei-Banuah et al.[17] (2021) reported poor knowledge of pregnant women about foods that help the body absorb iron (16.3%), and only 9.1% knew beverages that reduce iron absorption. Cultural contexts, geographic variations, research focus, and methodology were some of the contributing factors to these differences.

Frequency of black tea consumption per day

Nearly half the population drank 1–2 cups of black tea daily, and about one-third had drinking habits shortly after or after the meal. Further, we noted that participants who didn’t drink black tea demonstrated significantly better awareness of the association between black tea consumption and IDA (P = 0.035). Multiple mean differences suggested a significant difference in awareness between non-black tea drinkers versus those who consumed three or more black teas per day (P = 0.007). Better healthcare guidance, interest in nutrition, cultural factors, and personal experiences were some of the reasons why non-black tea drinkers possessed a better level of awareness than black tea drinkers. This is comparable to that of Nyakundi et al.[7] (2024), reporting that high tea consumption is positively associated with ID among women of reproductive age, which was also consistent with the previous reports of Asiko (2015).[13] In contrast, Hogenkamp et al.[18] (2008) documented that drinking black tea in black adults of race in South Africa does not significantly describe ID and IDA, suggesting that tea intake was not shown to influence iron status in various sub-populations at risk of ID. Potential factors for this effect include population diversity, regional settings, and study methodology.

Study limitations

The findings of this study account for some study limitations. First, the majority of respondents were females; hence, we cannot generalize the pairwise comparison between males and females and may need further investigation. Second, this study used a subjective questionnaire to measure awareness of the association between black tea consumption and IDA. Subjective questionnaires have several drawbacks, including a lack of standardization, interpretation challenges, and limited comparability. Lastly, being a cross-sectional study is prone to bias, such as limited insight into change over time and sampling bias, and is unable to measure cause and effect.

Conclusion

The awareness of the community regarding the association between black tea consumption and iron deficiency anemia was adequate. Female participants who had medical backgrounds and were non-black tea drinkers were associated with better awareness about the association between black tea consumption and IDA. Further, the community was aware of the most common symptoms and diagnosis of IDA, except for elevated blood pressure. In addition, most of them understood the food containing iron and the food that absorbs iron. Despite satisfactory awareness achieved by the community, there is still room for improvement. Improving community awareness about the relationship between black tea consumption and IDA requires a multi-faceted approach, including health education campaigns, engaging healthcare professionals, media involvement, policy, and community support.

Future aspects of the study

Future research should focus on larger-scale studies involving diverse populations across different regions within Saudi Arabia. Longitudinal studies are recommended to assess changes in community awareness and dietary behaviors over time. Moreover, exploring the effectiveness of specific educational interventions in improving community understanding about dietary factors influencing iron deficiency anemia could provide valuable insights for public health initiatives.

Non-author contributions

Statistical analysis was outsourced to a qualified statistical analyst. All other aspects of this research, including study design, data collection, and manuscript preparation, were conducted solely by the listed authors.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.