**Background:** Metabolic syndrome (MetS) is a cluster of interconnected metabolic diseases including central obesity, insulin resistance, hypertension, and dyslipidemia. Hematological abnormalities, particularly anemia, are common but often neglected complications of MetS that increase the risk of cardiovascular disease, stroke, heart failure, and chronic kidney disease. In Ethiopia, the pooled prevalence of MetS is 34.9%, yet data on hematological abnormalities in this population are scarce. This study aimed to determine the magnitude of hematological abnormalities and their associated factors among MetS patients at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia.
**Methods:** A hospital-based cross-sectional study was conducted from March to May 2022. A total of 384 MetS patients (defined by IDF criteria: central obesity plus any two of raised TG, reduced HDL-C, raised BP, or raised fasting glucose) were selected using systematic random sampling (K=2). Data were collected via pretested structured questionnaires, anthropometric measurements, blood pressure measurements, and venous blood samples for complete blood count analysis using a Beckman Coulter UniCel DxH 800 analyzer. Stool examination (saline wet mount) and blood film examination (Giemsa stain) were performed to detect intestinal and malaria parasites, respectively. Biochemical profiles (FBS, HDL-C, TG) were extracted from medical records. Anemia was defined per WHO criteria (Hb <13 g/dL for males, <12 g/dL for females). Leukopenia, leukocytosis, thrombocytopenia, and thrombocytosis were defined using hematological reference intervals for the Amhara region of Ethiopia. Data were entered into EpiData 3.1 and analyzed using Stata 14.0. Bivariate and multivariate logistic regression models were fitted; variables with p<0.25 in bivariate analysis were included in multivariate analysis. A p-value <0.05 was considered statistically significant.
**Key Results:** Of 384 participants, 239 (62.2%) were female; mean age was 60.8±10.2 years; 365 (95.1%) lived in urban areas; 175 (45.6%) were overweight; median BMI was 26.3 kg/m² (IQR: 24–29); median waist circumference was 100 cm (IQR: 96–107); 348 (90.6%) were on antidiabetic medications; 308 (80.2%) were on antihypertensive medications. The magnitude of anemia was 13.3% (95% CI: 9.9–16.7%). Among anemic patients, 62.7% had mild anemia, 25.5% moderate, and 11.8% severe; 74.5% had normocytic anemia, 21.6% microcytic, and 3.9% macrocytic. The magnitude of leukopenia was 0.5% (95% CI: 0.2–1.2%), leukocytosis 2.9% (95% CI: 1.2–4.5%), thrombocytopenia 1.6% (95% CI: 0.3–2.8%), and thrombocytosis 2.3% (95% CI: 0.8–3.9%). Factors significantly associated with anemia in multivariate analysis: male sex (AOR=2.65, 95% CI: 1.14–6.20, p=0.024), rural residency (AOR=5.79, 95% CI: 1.72–19.51, p=0.005), taking antihypertensive medications (AOR=3.85, 95% CI: 1.16–12.78, p=0.028), elevated triglyceride level ≥150 mg/dL (AOR=2.21, 95% CI: 1.03–4.75, p=0.042), and being overweight or obese (AOR=0.32, 95% CI: 0.16–0.64, p=0.001), which was protective.
**Clinical Implications:** Anemia was a mild public health problem (per WHO classification) among MetS patients in this setting, with a prevalence of 13.3%. The predominance of mild, normocytic anemia suggests anemia of chronic disease as a likely mechanism, driven by the chronic low-grade inflammation characteristic of MetS. The association with antihypertensive medications (particularly ACE inhibitors, which suppress erythroid precursors via angiotensin II reduction) highlights a potentially modifiable iatrogenic factor. Elevated triglycerides may contribute to anemia through increased erythrocyte fragility and hemolysis. The protective effect of overweight/obesity may relate to increased erythropoietin stimulation from obesity-related sleep apnea or better nutritional status. The higher odds in males may reflect hypogonadotropic hypogonadism and reduced testosterone-driven erythropoiesis in men with MetS. The higher odds in rural residents may relate to dietary inadequacy and limited healthcare access. Routine anemia screening should be incorporated into MetS management, especially for male, rural-dwelling patients on antihypertensives or with hypertriglyceridemia. Limitations include the cross-sectional design (no causal inference), use of saline wet mount only for stool examination (reduced parasite detection), lack of iron/B12/folate assays, and potential recall and social desirability biases.