(1) Background: Current diagnosis of anemia in high altitude populations uses an adjustment of observed hemoglobin (Hb) values. Such an approach has been challenged by findings in different populations in Tibet, Ethiopia and the Andes as inappropriate, as it might incorrectly classify an individual with complete iron stores as anemic. We aimed to assess the suitability of this approach in adult men and women from Cusco, Peru (3400 m); (2) Methods: Complete blood count and iron status biomarkers were measured in 345 subjects (189 females and 156 males), iron status biomarkers were quantified with enzyme-linked immunoassays; (3) Results: Anemia prevalence was overestimated when the altitude-adjustment factor was applied. Hematological parameters were better correlated to iron status biomarkers in the non-adjusted anemia category. When stratified by sex, only women showed a significant association between Hb and other hematological parameters with iron storage and availability (Hepcidin and TFR-F); (4) Conclusion: The prevalence of anemia is overestimated with current guidelines. The rate of anemia using non-adjusted Hb values is more closely related to the rates of anemia or iron deficiency when used hematological parameters, markers of iron status, and measurements of hepcidin and erythropoietin. Sex differences related to iron status were observed, suggesting that men are at a higher risk of iron overload than women at high altitudes. It could be highlighted that a personalized approach is important when assessing a subject, taking in to account hematological parameters as well as origin (Southern Andean or other).

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Introduction: According to the World Health Organization (WHO), anemia is a severe public health problem when the prevalence is ≥ 40%. In 2019, in Peru, 40.1% of children (age 6 to 35 months) are diagnosed as anemic. This is a concern since, despite the efforts of the governments to reduce the prevalence, the problem has stagnated since 2011. The treatment applied to deal with anemia is iron supplementation. Although iron is essential for cell function, an excess can produce adverse responses, such as gut inflammation affecting microbiota and resulting in diarrheic episodes. Objective: To determine the association between diarrhea and iron supplementation in children with and without anemia, controlling for different socio-demographic variables. Design: We conducted via logistic regression to obtain diarrhea prevalence ratios, adjusted by age, sex, geographic region, water and sanitation service, and rurality. The survey asked for recent episodes of diarrhea during the last 7 days; similarly, after the consumption of iron supplements during the last 12 months before the survey. Setting: Peru Subjects: The Demographic and Health Survey (DHS) is conducted annually at home among 14,202 children on average (2009 – 2019). Results: Iron supplementation in the last seven days (PR=1.09) or the last twelve months (PR=1.19) (p<0.0001) was associated with an increased risk of diarrhea. The same association was observed between iron supplementation and the presence of anemia. Conclusions: Iron supplementation is associated with diarrhea and over-use in children should be avoided.