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Ann N Y Acad Sci. Author manuscript; available in PMC 2022 March 01.
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Published in final edited form as:

Ann N Y Acad Sci. 2021 March ; 1488(1): 67–82. doi:10.1111/nyas.14520.

Changes in hemoglobin levels with age and altitude in

preschool-aged children in Peru: the assessment of two
individual-based national databases
Gustavo F. Gonzales1,2, Vilma Tapia1,2, Cinthya Vásquez-Velásquez1,2
1Laboratoriesof Investigation and Development and Department of Biological and Physiological
Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Lima,
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Peru.
2High Altitude Research Institute, Universidad Peruana Cayetano Heredia, Lima, Peru

Abstract
According to the World Health Organization, the cutoff hemoglobin (Hb) value for defining
anemia is 11 g/dL in preschool-aged children, and Hb measurements should be corrected above
an altitude of 1000 meters. This study sought to determine the altitude at which the Hb value
increases compared with that at sea level, Hb changes with age and region in Peru, the prevalence
of anemia according to three different models used to correct Hb for altitude, and the association
of the Hb value with stunting. Two individual-based Peruvian national databases were analyzed.
Hb increased from an altitude of 375 meters. Hb concentration was lower at younger ages and
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higher at older ages. The increase in Hb with increasing altitude was lower in southern Peru.
Implementing the different models for Hb measurement correction resulted in a higher and lower
prevalence of anemia at altitudes >2500 and <2500 m, respectively, using the CDC adjustment.
In children aged 6–23 months, the rate of stunting was lower in those with an Hb level of 10–12
g/dL (including mild anemia). In conclusion, the adjustment of Hb values for altitude should be
considered before 1000 m and reference ranges should be adjusted to smaller groups of children
instead of the same reference range for children aged 6–59 months.

Keywords
altitude adjustment; anemia; environmental health; erythrocytosis
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Address for correspondence: Cinthya Vásquez-Velásquez, Laboratories of Investigation and Development and Department of
Biological and Physiological Sciences, Faculty of Sciences and Philosophy, Universidad Peruana Cayetano Heredia, Av. Honorio
Delgado 430, Lima 15102, Peru. cinthya.vasquez.v@upch.pe.
Author contributions
V.T. and C.V.V. analyzed the results and created the figures. G.F.G. and C.V.V. designed the research and wrote the manuscript. All
authors reviewed and approved the final version of the manuscript for publication.
Competing interests
The authors declare no competing interests.
 Gonzales et al. Page 2

Introduction
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In 1958, the World Health Organization (WHO) joined experts in Geneva to discuss iron
deficiency anemia (IDA) and defined, for the first time, the hemoglobin (Hb) reference
values for anemia diagnosis.1 For infants and children aged 6–59 months, anemia was
defined as an Hb level <11 g/dL, and this definition has been the same since.2

In 1989, the WHO recommended an adjustment for interpreting Hb measurements, starting

at an altitude of 1000 m,3 whereby 0.2 g/dL is added to measured values at 1000 m and
4.5 g/dL at 4500 meters.2 During recent decades, various research groups have proposed a
redefining of the diagnostic criterion for anemia for children aged 6–59 months4–7 and those
living at higher altitudes, particularly altitudes above 3000 m of sea level.8–12

The WHO recommends a flat Hb value of 11 g/dL to define anemia in the age group 6–59
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months; however, current evidence suggests that the Hb level changes naturally during this
stage of life, with lower values at earlier ages and higher values at older ages.4–7 Relevant
studies have shown that the lower Hb reference value (minus 2 standard deviations (SD) of
concentration) is below 11 g/dL in children aged 6–35 months. These age-related changes
in Hb concentration in infants and toddlers result in a higher prevalence of anemia in the
younger group and a lower prevalence in older toddlers and children. These changes have
also been observed at different altitudes. However, the data at high altitudes11 are based on
those for the total population, regardless of nutritional status.

Several authors have questioned the need for correction of Hb values by altitude8–10,12 and
if it is needed, whether such correction should be applied universally. It is questioned if
individual factors, such as ethnicity, sex, age, or the generational antiquity (the duration
of time for which a population has lived in a particular place) of life at high altitudes
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in different populations living at elevations world-wide, should be considered for Hb

adjustments for altitude.

In Peru, the population living in the Southern Andes has greater generational antiquity than
the population living in the Central Andes.12 Furthermore, two ethnic populations living
in the Himalayas, the Tibetan and Han populations, have different generational antiquity
at high altitudes.13,14 Tibetan people have lived on the Qinghai–Tibet plateau (around
4500 m) for many generations and are well adapted to the high-altitude environment.13,14
Both genetic and archeological data suggest that Tibetans have been living on the Qinghai
Tibetan plateau since the late Paleolithic period (as early as approximately 30,000 years
ago). By contrast, the Chinese Han population has only resided at such high altitudes in
Tibet since the annexation of Tibet by China in the 1950s.15 Blood Hb concentrations
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are lower in the Tibetans than in the Han population living at the same altitudes.16 In
these groups, Hb correction for altitude has resulted in a higher prevalence of anemia in
the Tibetan population than in the Han population, but originates from the difference in
Hb concentrations between Tibetan and Han populations. This suggests that the universal
correction of Hb by altitude is not appropriate.

This pattern of Hb levels based on generational antiquity at high altitude is not restricted to
Asian populations alone. Recent studies have shown that the correction of Hb by altitude is

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inappropriate in the Asian, African, and Andean populations;8–10,12 consequently, the WHO
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references overestimate anemia in healthy, iron-sufficient Amhara, Tibetan, and Andean

highlanders. The population living in the southern highland region of Peru has longer
generational antiquity than the population living in the Central Andes and has lower Hb
levels, which are typically associated with a higher prevalence of anemia; however, they
have a lower prevalence of chronic mountain sickness, high birthweight, and lower stillbirth
rate.12

The high Hb concentration of the populations living at high altitudes is a response to the
low environmental oxygen pressure to which these populations are exposed. This results
in low arterial oxygen saturation. Arterial oxygen levels do not markedly decrease until
approximately 2500 m (8000 ft).17 However, a recent study18 in young male conscripts in
Switzerland demonstrated an increase in the mean Hb concentration, from 15.52 g/dL at
altitudes between 285 and <300 m, to 15.96 g/dL at altitudes ≥ 1800 meters. Although the
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study had not provided the values for altitudes between 0 and 285 m above sea level, its
findings contest the concept that Hb levels change with altitude above 1000 m, as suggested
by WHO, which recommends this threshold for Hb adjustment and for defining anemia in
high-altitude populations.2,3 Moreover, another recent study has suggested that Hb should
be corrected at altitudes below 1000 m, subtracting 0.1 g/dL for the altitudes 1–499 m
and 0.4 g/dL for the altitudes 500–999 meters.19 According to the authors of that study,
Hb values corrected as recommended by WHO are underadjusted for altitudes below 2000
m and overadjusted for higher altitudes. One of the limitations of these studies is that the
high-altitude study sample may have included persons born at lower altitudes who had
migrated to the highlands.

The objectives of the present study were to determine the altitude at which Hb increases
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compared with the values at sea level, changes in Hb by age and region of the individuals
living in Peru, the prevalence of anemia when using three different models to correct Hb for
altitude, and association of Hb value with stunting.

In this study, we used individual-based databases, rather than a population-based database as

used in the other studies.19

Materials and methods

This cross-sectional study analyzed data of children below the age of 5 years (6–59 months)
from the Nutritional Status Information System (SIEN in Spanish) provided by the National
Center for Food and Nutrition (CENAN) of the National Institutes of Health (INS in
Spanish) in Peru. The data included the anthropometric characteristics and Hb levels in
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children who attended public health facilities in Peru between 2012 and 2017. Hb was
measured using a portable HemoCue® 201 + hemoglobinometer (HemoCue, Ängelholm,
Sweden).20

The data were obtained from 7810 health facilities in Peru that hold the records of more
than 7938 health facilities associated with the SIEN. The total number of health facilities in
2017 was 8032. This implies that 97.2% of health facilities had reported records in the SIEN

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by 2017. Children attend these health facilities for scheduled growth and developmental
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checkups. At each visit, the parents were asked to estimate the number of multimicronutrient
(MMN) supplementation sachets (see below) that their child had consumed since the
previous visit.

The raw CENAN dataset used in this study included data on 2,127,392 children of both
sexes below the age of 5 years. Children with missing data for altitude (n = 9586) and those
below the age of 6 months (n = 118,701), 24 with missing data for age, and 158 with Hb
<4 g/dL were excluded, leaving data for 1,998,923 infants/children available for analysis. A
subanalysis of this population was performed using different cutoff points for the Z-score of
length/height-for-age (L-H/A; Fig. S1, online only). This subsample was used to calculate
the normal Hb values in healthy children (normal Z-score L-H/A).

This study also assessed data obtained from the Demographic and Health Survey (DHS)
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performed annually by the National Institute of Statistics and Informatics (INEI in Spanish)
in Peru. The DHS was conducted by the National Institute of Statistics and Informatics for
25 regions in the country (24 departments and 1 constitutional province). The data obtained
for 2012 and 2017 included 100,719 households. After exclusions, the final sample size
included 88,845 households (Fig. S2, online only). The DHS aimed to obtain and update
information on the population dynamics and health status of mothers and children under 5
years of age in Peru. For the surveys performed in 2012 and 2017, the sample framework
comes from the statistical and cartographic information collected in the National Census for
2007. The sampling was two-stage, probabilistic, and stratified at the departmental level and
by urban and rural areas.

The DHS information was collected by direct interviews conducted by trained INEI staff.
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This survey has national representativeness and allows the INS and the Ministry of Health
to monitor their health programs. The following variables were taken from the survey Hb,
Hb corrected according to the Centers for Disease Control and Prevention (CDC), anemia,
and anemia after correction of Hb by altitude, age, sex, altitude of residence, and if the
households had access to piped water and sewage systems, and socioeconomic status (SES).

Datasets from the CENAN and DHS do not include information on ethnicity.

Nutritional assessment
Nutrition was assessed using the method recommended by the SIEN, with the calculation of
the Z-score using the method recommended by WHO.21 Nutritional status was determined
according to the Z-score for L-H/A to assess stunting. The mean referenced by WHO and
the WHO-defined standard deviation of the reference population was used to calculate the
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Z-score. Stunting was defined as a Z-score less than − 2 for L-H/A. On the basis of the 2006
WHO growth standards, data were excluded if a child’s L-H/A Z-score was below −6 or
above +6.22

Diagnosis of anemia
Anemia was diagnosed in children aged 6–59 months with Hb levels <11 g/dL.2 Hb was
measured from the capillary blood using a HemoCue 201 + hemoglobinometer. Adjustments

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for altitude were published in 1989,3 on the basis of data from the CDC Pediatric Nutrition
Surveillance System and Peru.23,24 Additionally, Hb values were adjusted by altitude in
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preschool-aged children (PSC) using the equation devised by Sharma et al.19

Using data from the SIEN dataset, we developed an equation to adjust Hb by altitude using
a subsample of PSC with a Z-score for L-H/A 0 ± 2 SD. The tabulated data showing
adjustment of Hb for altitude are based on the lower point of the altitude range (e.g., 300 m
for the 300–349-m range).

Supplementation with MMNs

The SIEN/CENAN database contains the number of sachets of MMN consumed by each
child since the previous visit to the health facility. The MMN supplementation schedule
from 6 months of age onward consists of one sachet (1 g powder) daily for 12 continuous
months (360 sachets). Each sachet contains elemental iron (12.5 mg), zinc (5 mg), folic acid
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(160 μg), vitamin A (300 μg RE), and vitamin C (30 mg).

The guidelines from the Ministry of Health are that all children, anemic or not, aged 6–59
months should receive MMN sachets from the staff at the health facilities. According to the
Ministry of Health, adherence to the MMN supplementation is considered adequate when
≥75% of the indicated dose is consumed.25 This means that 23 or more sachets of MMNs
should have been consumed in the month preceding the checkup.

Ethical statement
The study protocol was approved by the Institutional Committee for Ethics and Research
of the Universidad Peruana Cayetano Heredia (SIDISI code: 202303). The requirement
for informed consent was waived given that this was a secondary database analysis and,
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therefore, did not involve direct contact with the study participants. The records for each
child in the database were identified by a code; names and any identifying information were
removed.

Statistical analysis
All statistical analyses were performed using the Stata statistical software package version
14.0 (StataCorp LP, College Station, TX). The Shapiro–Wilk test confirmed that the data
for the study populations in the two national databases were normally distributed (Fig. S3,
online only). The Hb value was obtained for each child at the altitude at which they resided;
however, for comparison, we grouped the data in altitude increments of 25 m, ranging from
0 to <500 m and from 500 to <1000 m and thereafter in 500-m increments up to 4700 m
above sea level.
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The data are reported as the mean and SD or as the median and percentile. Bartlett’s
test was used to test for homogeneity of variance. When the variance was homogeneous,
the differences among three or more groups were examined by analysis of variance.
Nonparametric tests were performed when a study variable did not show homogeneity of
variance. For data presented as frequency or percentage, between-group differences were
examined using the Chi-square test.

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To establish the Hb cutoff point that defines anemia in infants/children aged 6–59 months,
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we selected a group with an L/H-A Z-score ranging from − 2 to 2 SD. The cutoff points
were set by age group (6–11, 12–23, 24–35, 36–47, or 48–59 months) and by geographic
region (coast, mountains, or jungle), and an average value for each age was calculated at
each altitude level.

Higher Hb concentrations in urban regions and in more affluent populations23 were

taken into account when identifying our reference group for determination of the normal
distribution of Hb values. We then compared our results with data obtained from the SIEN
and DHS.

Pearson’s correlation coefficient (r) was used to study the associations between the two
quantitative variables. Multivariate logistic regression analysis was used to analyze the
risk of anemia, controlling for age, geographic region, and consumption of MMN. The
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association between various independent variables and the risk of anemia is represented as
the odds ratio.

The associations of variables, such as wealth, iron supplementation, availability of drinking

water, and sewage systems with Hb concentrations, and anemia were investigated using the
dataset obtained from the DHS.

P values of <0.05 were considered statistically significant.

Results
The distribution of subjects in 1000-m altitude increments in the CENAN dataset is shown
in Table S1 (online only) and that for the DHS dataset is shown in Table S2 (online only).
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The sample size in the DHS survey represents 4.4% of the sample size of CENAN. The
highest numbers of individuals resided at 0–999 and 3000–4700 m (3500–4700 m for DHS
data and 3000–3499 for CENAN data). The comparison between the two datasets showed a
lower percentage of 6- to 11-month-old children represented in the DHS dataset (Chi-square
test; P = 0.008). The distribution of children according to altitude in both datasets is similar
(Chi-square test = 9.20; P = 0.056).

Table S3 (online only) shows the mean age and Hb concentration in infants and toddlers
according to the altitude of residence, from 0 to 999 meters. This group represented 778,969
children in the CENAN dataset and 47,441 in the DHS dataset. The group in the DHS
dataset were older (P < 0.001) than the group in the CENAN dataset. The concentration of
Hb (g/dL) in the DHS dataset was higher than that in the CENAN dataset for all altitudes (P
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< 0.001), except at 225–249, 375–399, and 950–999 meters.

Table S4 (online only) includes data for children living at 1000–4700 m in 100-m
increments. This group represented 1,219,955 children in the CENAN and 35,784 in the
DHS datasets. The age and Hb concentration of children were higher in the DHS dataset.

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Hb increased with an increase in altitude from sea level to high elevations

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Figure 1A shows the regression curve for the relationship between altitudes from 0 to 1000
m and Hb concentration; there was a cubic association with values maintained without
changes in the range of 0–350 m, followed by an increase in Hb with an increasing altitude.
A quadratic association was observed between altitude and Hb concentration at altitudes of
1000–3000 m (Fig. 1B). At 3000–4700 m above sea level, there was a cubic relationship,
with a plateau at 4200–4700 m (Fig. 1C).

Hb concentration was calculated by altitude (in 200-m increments) according to the L/H-A
Z-score (Table S5, online only). The Hb level was clearly higher from 0 to 199 m above
sea level in the group living at 400–599 meters. The highest mean Hb value was observed
in those with an L/H-A Z-score between −2 to +2 SD. This group was used to construct a
normal curve of reference for Hb level by altitude.
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Figure 2 shows the regression curve for altitude and Hb over the altitude range of 0–4700
meters. The best association was quadratic, without changes at 0–200 or 4200–4700 m
above sea level.

Age-related changes in Hb levels in PSC born and residing at different altitudes

According to CENAN and DHS data, Hb concentration was lower in younger and higher in
older PSC aged 6–59 months. Hb concentration (g/dL) increased 1.08- (CENAN) and 1.10-
(DHS) times from the ages of 6–11 to 36–59 months. Using the Hb cutoff value of 11 g/dL,
the prevalence of anemia was higher in children aged 6–11 months, intermediate in those
aged 12–35 months, and lower in those aged 35–59 months in both datasets (Table 1). On
the basis of the WHO cutoff and uncorrected Hb values, from the age of 6–11 to 36–59
months, the prevalence of anemia was reduced 0.51-fold based on the CENAN dataset and
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0.32-fold based on the DHS dataset. No sex-related difference was observed in this age
pattern. However, Hb concentration was lower in boys, in whom the sub-sequent prevalence
of anemia was higher than that in girls.

Figure 3A shows the mean Hb concentrations (with 2 SD) in PSC aged 6–59 months who
reside at ≤1000 and >1000 m above sea level; for both altitudes, mean Hb concentration
was lower for the younger ages and higher at older ages. At all ages, Hb concentration was
higher at altitudes >1000 m than at lower altitudes. All values of Hb at 2 SD were below 11
g/dL, defined by WHO as the cutoff point for anemia diagnosis.

Figure 3B shows the association between altitude and Hb concentration in the three age
groups. Hb concentration was highest in the group aged 36–59 months, intermediate in those
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aged 12–35 months, and lowest in those aged 6–11 months.

In the CENAN dataset, Hb concentration increased with an increasing altitude, independent

of age. Children living at altitudes of 375–399 m had higher Hb values than their
counterparts residing at 0–24 meters. Hb values in PSC changed significantly from a mean
value of 11.17 g/dL at 0–24 m to 11.41 g/dL at 375–399 m (P < 0.01) (Table S3, online
only). The following groups above 375 m are not significant with respect to Hb values at
0–24 m (475–499, 500–549, and 850–899 meters).

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In the DHS dataset, children living at altitudes of 400–424 m had higher Hb values than
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those at 0–24 m (P < 0.001). Hb levels in the groups at 425–449 and 475–499 m are not
significant with respect to values in children at 0–24 m (Table S3, online only).

The pattern of lower Hb levels in younger children and higher Hb levels in older children
was independent of SES (Table S6, online only). In children living at altitudes <1000 m, Hb
varied from 10.9 ± 1.1 g/dL in the poorest group to 11.7 ± 1.0 g/dL (P < 0.001) in the richest
group. At altitudes ≥1000 m, no differences in Hb levels were observed between the SES
groups. This suggests that SES would confound the data presented in Table S3 (online only).

Further analysis showed that PSC living at high altitudes were socioeconomically worse
than those living at a lower altitude. The equation obtained for the calculation of Hb
considering diverse variables of interest using the DHS dataset would be the following one:
Hb =10.344 + 0.0286 (age) −0.1053 (men) − 0.3466 (mountain) − 0.3833 (jungle) + 0.0007
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(altitude) −0.078 (rural) +0.1039 (sewage systems) + 0.2478 (upper wealth quintile) (Table
S7, online only). For example, with this equation, a boy, a 36-month-old resident of the
urban jungle (120 m), with sewage systems, and belonging to the upper wealth quintile,
will have an Hb value of 10.344 + 0.0286∗(36) −0.1053∗(1) −0.3466∗(0) −0.3833(1) +
0.0007∗(120) − 0.078∗(0) + 0.1039∗(1) + 0.2478∗(1) 11.32 grams per deciliter. A female
child, a 59-month-old resident of the rural mountain (3000 m), with sewage systems, who
does not belong to the upper wealth quintile will have an Hb value of 10.344 + 0.0286∗(59)
− 0.1053∗(0) − 0.3466∗(1) − 0.3833∗(0) + 0.0007∗(3000) −0.078∗(1) + 0.1039∗(1) +
0.2478∗(0) = 13.82 grams per deciliter.

Multivariate analysis showed that older age (OR = 0.94; P = 0.0001), female sex (OR =
0.84; P = 0.007), increasing the altitude of residence (OR = 0.97; P = 0.0001), availability
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of sewage systems at home (OR = 0.73; P = 0.0001), and wealth status of the child’s family
(OR = 0.61; P = 0.0001) were associated with a lower likelihood of anemia. Living in the
jungle was associated with a higher OR for anemia (Table S8, online only).

Comparison of different Hb cutoff values by altitude

The equation of the curve in Figure 2 was used to construct our adjustment for Hb
measurements by altitude (Table 2). The adjustment required when using the equation
devised by Sharma et al.19 was similar to that obtained with our approach but was higher
than that required when using the CDC method at altitudes <2500 m and lower at altitudes
≥2500 meters. Table 2 shows the proposed adjustments of Hb by altitude according to our
equation (0.1 g/dL at 300 m), the equation devised by Sharma et al. (0.1 g/dL at 200 m), and
the CDC recommendation (0.11 g/dL at 700 meters).
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These differences in adjustment using the different models resulted in a higher prevalence of
anemia at altitudes ≥2500 m when using the CDC method3 than when using the adjustment
method of Sharma et al.19 or that devised by our group. By contrast, the prevalence of
anemia at lower altitudes (<2500 m) was lower when using the CDC method than when
using the other two models (Fig. 4A and B). Our curve for the prevalence of anemia was
similar to that obtained by Sharma et al.19 The same pattern was observed using CENAN

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and DHS data. However, the prevalence of anemia was higher with the CENAN data (Fig.
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4A and B).

The cutoff Hb values defining anemia according to age and altitude are included in Table 3.
These values correspond to the −2 SD Hb concentrations of a selected population with an
L/H-A Z-score between −2 and +2 SD. The cutoff point increased with increasing altitude
and age. Cutoff values of Hb at −2 SD for defining anemia were 8.63, 8.95, and 9.57 g/dL at
ages 6–11, 12–35, and 36–59 months, respectively, in the group of children living at 0–499
m, and 10.05, 10.48, and 11.31 g/dL for these three age groups, respectively, in children
living at ≥4000 meters.

Table S9 (online only) shows the prevalence of anemia according to age calculated based on
the group with L/H-A Z-scores between −2 and +2 SD in the CENAN and DHS datasets.
Anemia was calculated according to the adjustment for altitude suggested by CDC, Sharma
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et al., and our group. The prevalence of anemia was higher in the groups with adjusted Hb
than in those without Hb adjustment for altitude.

Without Hb adjustment for altitude, the prevalence of anemia was similar in the CENAN
and DHS datasets. With Hb adjustment for altitude, the prevalence of anemia was higher in
the CENAN data than in the DHS data. Adjustment with CDC equation resulted in a higher
prevalence of anemia than from using equations from Sharma et al. and our group. The
prevalence of anemia was similar when the adjustment from Sharma et al. and our group was
used.

Independent of the adjustment of Hb by altitude, the prevalence of anemia was highest in

the group aged 6–11 months, intermediate in the group aged 12–35 months, and lowest
in the group aged 36–59 months. Compared with the older age groups, anemia was 3.46
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times more common, according to the CENAN data without Hb adjustment for altitude, and
2.09–2.23 times for adjusted Hb. According to the DHS data, the prevalence of anemia was
3.59 times higher without Hb adjustment and 3.02–3.22 times with adjustment in the older
group.

When anemia was defined as an Hb value lower than −2 SD for the age group, the
prevalence of anemia was lower than that when a flat value of 11 g/dL was used (Table
S10, online only). The prevalence of anemia without adjustment of Hb for altitude and
when using a cutoff Hb value of −2 SD for the age group was lower than that when Hb
was adjusted by altitude. For example, in infants 6–11 months of age, when using the
DHS dataset, the prevalence of anemia varied from 9.72% (95% CI: 9.07–10.3) with Hb
adjustment by altitude, to 6.53% (95% CI: 6.00–7.09%) without Hb adjustment by altitude.
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Altitude-related changes in Hb in the Northern, Central, and Southern Andes

As shown in Table S11 (online only), the increase in Hb with altitude was lower in southern
Peru than in central Peru at 1000–1999, 2500–2999, 3000–3499, and 3500–4700 meters.
Moreover, Hb values at 3000–3499 m were higher in central Peru than in northern Peru.

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Association of the Hb level with stunting

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Figure 5A–D shows the association between Hb and stunting according to age group using
data from CENAN (Fig. 5A and B) and DHS (Fig. 5C and D). Lower stunting rates were
observed for individuals with Hb values in the range of 10 g/dL in the group aged 6–35
months and 11–12 g/dL in the group aged 36–59 months. Percentage of children with
stunting was higher at 36–59 months than that at 6–35 months. The prevalence of stunting
was higher in the CENAN dataset compared with the DHS dataset at 36–59 months.

Discussion
Around a third of the world’s population is diagnosed with anemia, which is considered to
be one of the unresolved global public health burdens. It is recognized that PSC aged 6–59
months are particularly vulnerable to anemia.26 Most governments have been combatting
anemia since the 1960s. However, despite the global efforts made to reduce anemia in
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infancy, the results are modest, and in several regions, there has been an increase in
prevalence, as demonstrated in a recent study in the highlands of Bolivia.27

The modest or lack of response to intervention programs aimed at reducing anemia may, in
part, reflect the arbitrary diagnostic criteria used to define the disorder,1 whereby a flat Hb
cutoff value of 11 g/dL has been used to define anemia in all children aged 6–59 months.
Furthermore, the WHO has recommended Hb to be adjusted by altitude from 1000 m and
higher above sea level when defining anemia.2,3 The reason for this recommendation is
unclear, given that Hb concentrations also appear to be higher at altitudes lower than 1000
meters.18,19

Noting that the cutoff points recommended by WHO for the diagnosis of anemia have been
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questioned in a number of studies,4,6–12,18,19 here, we investigated whether Hb cutoff values

as defined by WHO are adequate. This study used two large individual-based datasets,
which are more informative than the population-based datasets used in other systematic
studies.19,28 We assessed the data collected by two Peruvian governmental organizations
(CENAN and INEI) between 2012 and 2017, for PSC aged 6–59 months residing at altitudes
of 0–4700 m above sea level.

We found that Hb concentration changed with age, from 6 to 59 months, with lower values
recorded at younger ages and higher values at older ages. This age-related pattern of an
increase in Hb concentration, independent of altitude, was observed in a subsample of PSC
with normal nutrition and higher SES. The data indicated that Hb concentration at any
altitude is lower at 6–11, intermediate at 12–35, and higher at 36–59 months, which is
consistent with the earlier reports.4,5,9,29,30
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Our findings are consistent with the suggestion that physiological Hb values are lower in
young infants, even in those who have adequate iron stores than that in older children.31
The age-related physiological changes imply that the normal values also change according to
age, which is in conflict with the suggestion from the WHO that a flat Hb threshold value of
11 g/dL should be used to define anemia in children aged 6–59 months.2

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 Gonzales et al. Page 11

Neonates have a high Hb level as a consequence of greater erythropoiesis in the hypoxic

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environment in utero, but after birth, the infant transitions to an aerobic environment
in which this high Hb level is degraded. Neonates have predominantly fetal Hb, which
is gradually replaced by adult Hb in the first 1–2 years of life32,33 via the process of
neocytolysis,34 which selectively destroys erythrocytes formed during stress erythropoiesis
in a hypoxic environment in order to increase the oxygen transport capacity in the blood.35
Iron from Hb that is degraded after birth is recycled and stored in the liver and hematopoietic
organs. Therefore, in childhood, Hb values can be low, even in the presence of an adequate
iron reserve. Hb concentration is lower at earlier ages but increases with the production of
adult Hb. The WHO recommendation to use an Hb value <11 g/dL for diagnosis of anemia
in children aged 6–59 months does not account for these physiological changes. It has been
suggested that the higher prevalence of apparent anemia in children aged 6–35 months is
more because of the normal decrease in postpartum Hb, which may fall below the cutoff
point of 11 g/dL, than to actual anemia.30
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Another question regarding the WHO recommendations used to define anemia is the
adjustment of Hb by altitude. The WHO has recommended adjustment of an Hb value
by altitude from 1000 m above sea level, but the criteria for assuming that Hb would start
changing at an altitude of 1000 m are not clear. In the present study, we have demonstrated
that Hb changed significantly at lower altitudes, from 11.17 g/dL at 0–24 m to 11.41 g/dL at
375–399 m using the CENAN dataset and from 11.39 to 11.43 g/dL at 400–424 m using the
DHS dataset.

In addition, our study showed that the increase in Hb with altitude in the Andes region
was higher than that observed in a previous study of young men in Switzerland.18 Our own
and the previous study findings suggest that the magnitude of an increase in Hb by altitude
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may vary between regions,36 and also among ethnic groups within a region, as suggested
previously.37 This is important to consider if adjustment of Hb by altitude is accepted.

In the Andean region, the magnitude of an increase in Hb by altitude in adults was found
to be higher (1 g/dL per 1000 m) than in the other regions of the world (0.6 g/dL per 1000
m).36 A previous study found that Hb levels in healthy adult male and female blood donors
(18–35 years) increased with altitude, from 200 to 300 m below sea level to 500–1500 m,38
with men and women living at 500–1500 m, respectively, having Hb levels 0.4 and 0.5 g/dL
higher than those living below sea level.

A previous study on subjects living from 250 m below sea level to 3109 m above sea
level unequivocally demonstrated that Hb increases with altitude in both sexes.38 However,
whether the increase should be seen as a continuum from sea level or only from a barometric
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pressure threshold remains unresolved.

Our results confirmed that Hb increased significantly from 300 to 400 m above sea
level. This variation seems to be independent of changes in SpO2. A recent study that
included 31,967 observations for PSC from 12 countries showed that Hb started to increase
significantly with altitude from 250 m above sea level.19 This difference in the pattern of

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 Gonzales et al. Page 12

an Hb increase with altitude in different ethnic populations should be considered when

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reviewing the current cutoff point for defining anemia at high altitude.

Several models have been developed for adjusting Hb by altitude. Adjustment is

recommended for PSC and for men and women of all ages2,3 as well as for all populations
living at high altitudes worldwide. However, different studies have demonstrated that the
association between Hb and altitude depends on the population group (young children versus
women of reproductive age),19 ethnicity (Tibetan versus Han),37 and region (Andean versus
European),36 suggesting that altitude-based adjustments may need to be tailored according
to the population group.

In our study, we noted that the increase in Hb was greater at altitudes of 1000–2500 m, and
lower at altitudes >3000 m, than the levels suggested by WHO. Moreover, the magnitude of
the difference of Hb by altitude according to the WHO and our original data in PSC from
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Peru increased as altitude increased higher than 3000 m, which is consistent with a previous
report.19

Our proposed adjustment of Hb by altitude differed markedly from that recommended by

CDC but is similar to that proposed recently.19 Our findings suggest that the prevalence of
anemia is underestimated when using the CDC adjustment at altitudes below 3000 m and
overestimated at altitudes above 3000 meters. Therefore, we propose a table for adjustment
of Hb values by altitude and age that can be used for PSC.

One of the problems with the development of models for adjusting Hb by altitude to define
anemia is that the relevant studies were not designed to examine the relationship between
Hb concentration and health outcomes. We have previously demonstrated that the correction
of the Hb cutoff value used to define anemia in pregnant women living at high altitude
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reduces the risk of adverse perinatal outcomes by showing that iron-replete women were
misdiagnosed as anemic and did not have adverse perinatal outcomes.39 Moderate-to-severe
IDA, but not mild anemia, early in the third trimester was associated with neonatal births
that were small for gestational age.40 Moreover, a better birthweight outcome was observed
with mild anemia than with Hb concentration ≥11 g/dL.41

In the present study, we observed a better growth outcome in PSC with an Hb level of 10–11
g/dL, just in the range of mild anemia, particularly at earlier ages, suggesting that values
indicating mild anemia have no adverse effect on infant growth. This supports the notion that
the Hb cutoff point of 11 g/dL to define anemia in PSC should be reevaluated.

Studies of life at high altitude show a consistent association between Hb and altitude.
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However, when individuals with different generational antiquity at the same high altitude
are studied, those with multigenerational residence at high altitudes tend to have lower Hb
levels than those with a shorter exposure to such altitude. This has been observed among the
Tibetan and Han populations in the Himalayas.16 Approximately 5.5 million people living
in the South American Andean region are Aymaras, an ethnic group living on the Altiplano
of Bolivia, Peru, and northern Chile, at altitudes of up to 4400 meters. The generational
antiquity of this population is more than 2000 years with constant evolutionary pressure on
its inhabitants for genetic adaptation to high altitude.42

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 Gonzales et al. Page 13

We have demonstrated in this study that the altitude-related increase in Hb in PSC living
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in southern Peru is less than that in their counterparts living in the Central Andes. These
low Hb values more likely reflect the process of adapting to life at high altitude than
genuine anemia; this suggestion is supported by the finding that birthweight is optimal in
the Southern Andes in Peru.43 Neonates born to mothers with a considerable component
of Aymara ancestry did not show the characteristically reduced birthweight at higher
altitude.44 Patterns of variation in birthweight according to the altitude of residence and
Aymara ancestry indicate that populations in this region may be partially protected from
the challenges that hypoxia imposes on the fetus.45 The Aymara have been living at high
altitudes for more than 350 generations, enabling genetic variants that were either slightly
advantageous or neutral at low altitude to become advantageous at high altitude.44

Our data demonstrated that low Hb levels in the Southern Andes are physiologically
normal; however, interpretations of these levels are affected by adjustment of Hb for
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altitude. An observational study that assessed Hb levels, iron status, and the suitability of
altitude-adjusted Hb values for defining IDA in PSC living at high altitudes in the Southern
Andes of Peru showed that the prevalence of anemia was 66% after adjustment for altitude,
whereas it was only 4.8% without such adjustment.12 Several research groups have argued
against the recommendation to correct Hb concentrations for altitude on the grounds of a
seemingly disproportionate increase in the rate of anemia, particularly at altitudes over 3000
meters.8–12,19,30,46

The recent findings of Sherpa demonstrating a larger plasma volume than Andeans, resulting
in a comparable total blood volume at a lower Hb concentration, confirmed the hypothesis
that the lower Hb concentration is the result of a greater plasma volume, rather than a lack of
increased Hb production.47 In these circumstances, subjects should be considered as having
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hemodilution, rather than genuine anemia.

Another problem with the correction of Hb by altitude is that there is a decrease in the
upper limit of Hb values. For example, at 4500 m, an Hb value of 22 g/dL, which is
considered to indicate excessive erythrocytosis, is reduced to 18.5 g/dL and considered to
be normal after correction. However, the clinical significance of excessive erythrocytosis,
regardless of cause, lies in the associated risk of thrombotic events as a result of
hyperviscosity of the blood.48 The demonstration that both hyperviscosity and high Hb
actively contribute to acutely reversible impairment in flow-mediated dilation in cases with
excessive erythrocytosis suggests that both components are important contributors to the
increased cardiovascular risk.49 Indeed, we can mathematically reduce the actual value of
Hb but the actual effect will be sustained, as viscosity will not be reduced in reality.
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Our study had some strengths, in that we were able to examine associations with Hb using
individual-based data, instead of the population-based data used in the other systematic
studies. We used the DHS dataset, which is representative of all regions in Peru, and the
CENAN dataset, and found the same patterns in both datasets. This approach enhanced our
ability to examine Hb across a wide range of altitudes, with control of different variables in
the analysis by using the DHS dataset. However, we found that age and altitude distributions
vary between datasets.

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 Gonzales et al. Page 14

The age of children in the DHS dataset was higher than in the CENAN dataset. This was
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associated with higher Hb level in the DHS data. This is due to the fact that children of
younger age are attending in a higher proportion to the health facility service for growth
control than the older children, whereas data from DHS are representative of the overall
population controlled for age, sex, and altitude.

Children attending services of the Ministry of Health represents a population of low and
mid-low SES, whereas data obtained by DHS include this population but also those with
high SES. Thus, differences in the prevalence of anemia between the datasets suggest that
confounding variables should be taken into account for a final model to be used in the
assessment of Hb values in Peruvian children.

The main limitation of the study was the bias from the digitization of two such large
datasets. The CENAN dataset represents a population of infants that serve as medical
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controls, but do not reflect the total population; however, the DHS dataset is a representative
sample given that the population was selected at random.

Other limitations were the lack of data on ethnicity in both surveys, the inability to
generalize the study findings beyond Peru, and acclimation to altitude. As this was a
cross-sectional study, it was impossible to deduce a cause–effect relationship. Although
we have studied the effect of anemia on growth (stunting), further studies are required
to demonstrate an association between anemia and other adverse outcomes, such as
neurocognitive development. Evidence regarding the effect of iron supplementation on
neurological development in preterm and low birthweight infants is limited, and further
research is required.50
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Conclusions
The adjustment of Hb values for altitude should occur earlier than 1000 m and reference
ranges should be adjusted to smaller groups of infants instead of the same reference range
for children aged 6–59 months. Our data also suggest that Hb adjustment at altitudes <3000
m is greater and that at altitudes >3000 m is smaller than that estimated by CDC. Therefore,
the Hb correction factor proposed by WHO must be revised. The lower Hb values in the
southern highlands of Peru seem to reflect the longer generational antiquity of living at high
altitude in this population. Moreover, the low stunting rate in infants with mild anemia living
at high altitude suggests that the cutoff point of Hb that is currently used to define anemia
should be reexamined.

Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
G.F.G. and V.T. were supported by the National Institutes of Health Fogarty International Center, the National
Institutes of Environmental Health Sciences, the National Cancer Institute, the Centers for Disease Control and
Prevention, and the National Institutes of Health (NIH) under Award Number for research Grant U01 TW0101 07
(GEOHealth Hub Grant). The content is solely the responsibility of the authors and does not necessarily represent
the official views of the NIH.

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 Gonzales et al. Page 15

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Figure 1.
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(A) Mean Hb values in preschool-aged children living at altitudes of 0–500 m, in 25-m

increments, and 500–1000 m, in 50-m increments (y = −2e−9x3 + 3e−6x2 + 0.0006x + 11.10;
R2 = 0.46; P < 0.001). (B) Mean Hb values at altitudes of 1000–2999 meters (y = e−7x2 +
0.0002x + 11.26; r2 = 0.88; P < 0.001). (C) Mean Hb values at altitudes of 3000–4700 m (y
= −6e−10x3 + 7e−6x2 − 0.025x + 41.73; R2 = 0.85; P < 0.001). Sample size: (1) 0 to <1000
m: 778,969 children; (2) 1000 to <2999 m: 581,544 children; and (3) 3000–4700 m: 638,410
children. Total sample size: 1,998,923 children. Source: CENAN.

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Figure 2.
Quadratic relationship between altitude (0–4700 m) and Hb in preschool-aged children, aged
6–59 months, with a Z-score for length/height-for-age of −2 to +2 SD. Each point represents
an increment of 200 m in altitude. y = 4e−8x2 + 0.0005x + 11.024 (r2 = 0.9849; P < 0.001),
this equation was used to construct the adjustment of Hb by altitude. Total sample size:
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1,561,178 children. Source: CENAN.

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 Gonzales et al. Page 20
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Figure 3.
Changes in Hb concentration with age in preschool-aged children (PSC) in Peru. (A)
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Changes in Hb concentration with age in PSC living at altitudes <1.000 m (N = 53,061)

and ≥1000 m (N = 35,784). Source: DHS. Solid lines correspond to mean values and dashed
lines correspond to 2 standard deviations (SD). Total sample size: 88,845 children aged 6–59
months. The red line represents the World Health Organization (WHO) Hb threshold for
anemia diagnosis. P < 0.001 for comparison of low- and high-altitude living for each age
group. (B) Quadratic association between altitude (m) and Hb (g/dL) for infants and children
in different age groups. Data are shown for altitudes in 200-m increments (e.g., 0–199,
200–399, and 400–599 meters). The upper line corresponds to the PSC group aged 36–59
months (black triangles). The middle line corresponds to the group aged 12–35 months (gray
squares). The lower line corresponds to the group aged 6–11 months (black rhombus). P <
0.001 across age groups for each level of altitude. Total sample size: 1,998,923 children.
Source: CENAN.
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Figure 4.
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The prevalence of anemia at altitudes of 0–4700 meters. Hemoglobin (Hb) was corrected by
altitude as recommended by the CDC (black line), and values of Hb <11 g/dL were used
to define anemia at 6–59 months of age. Hb was corrected by altitude as recommended by
Sharma et al. (black dotted line) and Hb values <11 g/dL were used to define anemia at
6–59 months of age. The prevalence of anemia according to the adjustment method used by
Gonzales et al. is in gray dotted line. P < 0.001 was obtained in all models. (A) CENAN and
(B) DHS datasets.

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Figure 5.
The association between uncorrected Hb levels and stunting in infants in various age groups.
The CENAN data: (A) Age group 6–35 months (N = 1,509,652). (B) Age group 36–59
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months (N = 489,271). The DHS data: (C) Age group 6–35 months (N = 48,752). (D) Age
group 36–59 months (N = 40,090). Total sample size: the CENAN dataset: 1,998,923; and
the DHS dataset: 88,845 children.
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Table 1.

Mean hemoglobin and prevalence of anemia in preschool-aged children (6–59 months) according to sex and
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age groups from Peru

Dataset CENAN DHS

Age Female Male Female Male

(months) (981,392) (1,017,531) (43,411) (45,434)

Hb* a
Anemia %, Hb* a
Anemia %, Hb* a
Anemia %, Hb* a
Anemia %,
mean ± 95% CI (N) mean ± 95% CI (N) mean ± 95% CI (N) mean ± 95% CI (N)
SD SD SD SD
6–11 11.66 ± 56.24: 56.0‒ 11.57 ± 58.80: 58.6– 11.44 ± 57.09: 55.2‒ 11.17 ± 62.46: 60.6‒
1.49 56.4 1.51 59.0 1.60 58.9 1.62 64.2
(139,175) (150,328) (2540) (2962)

12–35 12.09 ± 45.00: 12.04 ± 46.67: 46.5– 11.86 ± 38.60: 37.7‒ 11.77 ± 41.51: 40.6‒
1.51 44.8−45.1 1.52 46.8 1.46 39.4 1.51 42.3
(222,660) (238,834) (7610) (8439)

36‒59 12.65 ± 28.81: 28.6‒ 12.63 ± 29.87: 29.6– 12.48 ± 18.01: 17.3‒ 12.40 ± 21.21: 20.5‒
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1.45 28.9 1.44 30.0 1.40 18.7 1.39 21.9

(68,902) (74,697) (3466) (4299)

N, the number of children is shown within the parentheses. 95% CI, confidence interval at 95%; SD, standard deviation.
*
T-Student’s t-test.
a
Chi-square test P < 0.0001 between boys and girls, and between the three age groups. Each pair of the mean Hb was different. Source: Datasets
from CENAN (1,998,923), 2012–2107, and DHS (88,845), 2012–2017.
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 Gonzales et al. Page 24

Table 2.

Proposed adjustment increments from 1000 to ≥4500 m by population group according to three different
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equations

Altitude (meters) Adjustment according Gonzales et al. Adjustment according Sharma et al. Adjustment according CDC
0 0.00 0.00 0.00
50 0.02 0.02 0.00
100 0.03 0.05 0.00
150 0.05 0.07 0.00
200 0.06 0.10 0.01
250 0.08 0.12 0.01
300 0.10 0.15 0.02
350 0.12 0.17 0.03
400 0.13 0.20 0.03
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450 0.15 0.22 0.04

500 0.17 0.25 0.05
550 0.19 0.27 0.07
600 0.21 0.30 0.08
650 0.23 0.32 0.09
700 0.25 0.35 0.11
750 0.28 0.37 0.13
800 0.30 0.40 0.14
850 0.32 0.43 0.16
900 0.34 0.45 0.18
950 0.37 0.48 0.20
1000 0.39 0.51 0.23
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1100 0.44 0.56 0.27

1200 0.49 0.61 0.33
1300 0.54 0.67 0.39
1400 0.60 0.72 0.45
1500 0.65 0.78 0.52
1600 0.71 0.83 0.59
1700 0.77 0.89 0.67
1800 0.83 0.94 0.75
1900 0.89 1.00 0.83
2000 0.96 1.06 0.93
2500 1.31 1.35 1.45
3000 1.71 1.66 2.10
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3500 2.15 1.98 2.86

4000 2.64 2.31 3.75
4500 3.17 2.65 4.75

Note: The models used to obtain the adjustments of Hb by altitude are shown in Figure 4. Source: CENAN 2012–2017.

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 Gonzales et al. Page 25

Table 3.

Values of −2 SD of hemoglobin (g/dL) in infants and toddlers aged 6–59 months, residing at different altitudes
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and with Z-score for length/height-for-age from −2 to +2 SD.

Altitude (m) 6–11 months 12–35 months 36–59 months

0–499 8.63 8.95 9.57
500–999 8.87 9.12 10.76
1000–1999 9.14 9.49 11.16
2000–2999 9.54 9.98 11.82
3000–3999 9.73 10.19 10.94
≥4000 10.05 10.48 11.31

Note: Total sample size: 1,998,923 children. Source: The dataset obtained from CENAN 2012–2017.
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Ann N Y Acad Sci. Author manuscript; available in PMC 2022 March 01.