Paradox of Iron Deficiency Anemia Despite Adequate Iron Intake Among Women of Childbearing Age in Adjumani Refugee Settlement, Northern Uganda

Background: Anemia remains a major concern among women of childbearing age (WCBA) in refugee settings, driven by food insecurity, poor dietary diversity, infections, and inadequate sanitation. However, despite reported adequate iron intake, the contribution of iron deficiency anemia to overall anemia prevalence remains poorly understood, creating an important evidence gap. This study investigated: (i) dietary iron intake; (ii) contribution of iron deficiency to anemia prevalence and (iii) socio-economic and dietary factors influencing serum iron status of WCBA. Methods: A cross-sectional survey was conducted among 462 non-pregnant WCBA. Dietary intake was assessed using a seven-day food frequency questionnaire, and daily iron intake was estimated using Harvestplus food composition tables. Hemoglobin levels were measured with a HemoCue Hb 301 analyzer,and IDA was determined by analyzing serum ferritin using Human Ferritin ELISA kit (Bio-techne company, United Kingdom), following standard procedure and manual from the manufacturer. Results: Average dietary iron intake was not significantly different (p ≤ 0.05) from recommended daily intake (RDI) of iron except for one refugee settlement. The intake of iron was largely from plant sources. Overall anemia prevalence was 34.4%, with a mean hemoglobin concentration of 10.76 g/dL. Iron deficiency anemia (IDA) accounted for 37% of anemia cases, with variation across settlements: Adjumani East recorded 58% prevalence compared to 17% in Adjumani West. Socio-economic factors including education, income-generating activities, and household income significantly influenced serum ferritin levels (p < 0.05). Food consumption patterns revealed reliance on cereals and legumes, with minimal intake of iron-rich animal products. Conclusions: Despite reported iron intake near recommended levels, iron deficiency anemia remained high, highlighting the poor bioavailability of plant-based iron sources. Nutrition interventions should prioritize dietary diversification, encouraging inclusion of animal-source foods and enhancers of iron absorption. Strengthening economic opportunities for refugee women may improve access to nutrient-rich foods and reduce anemia prevalence. These findings underscore the paradox of adequate intake but persistent deficiency, offering novel insights for targeted nutrition strategies in humanitarian contexts.