Faculty of Education, University of Khartoum, Khartoum Omdurman 406 Sudan
2
Rufaa Nutrition and Maternity Office, Ministry of Health, Gezira state, Sudan
*Corresponding Author: samiralredaisy@yahoo.com
Received 24 April 2013; Accepted 5 June 2013
Abstract. This study investigated factors influencing nutritional status of children less than five years old suffering anemia and night blindness in Khartoum State. Sample size was 138 children determined by 10% rate of prevalence of nutritional deficiency diseases among children living in Khartoum State. In addition, testing hemoglobin and anthropometric measurements were done. Results depicted that, illiteracy was prevailing, and household monthly income averaged 100 USD.
Symptoms of anemia included loss of appetite (8777%), paleness (9375%), and eating clay (29%), while for night blindness they were xerophthalmia (20%); Pinot spots (52%); karatomalacia (12%), and Cornea ulceration (4%). Children suffering these two diseases had hemoglobin concentration below 60% standard, indicated to Iron deficiency anemia and cute malnutrition constitute 63% of the cases. Females are less malnourished compared to males. Significant relationship exists between household monthly income and number of meals per day taken by a child (P=0 .0003); and between nutritional status of children and number of meals taken by a child per day (P=0 .003); and between household monthly income and frequency of daily intake of energy, protein, iron by a child (0.04; 0.01; 0.07 respectively). Nutritional status of pregnant women and nutritional status of the family are significantly correlated (P= 0.0056); and hemoglobin and intake of animal and plant protein is significant correlated (P= 0.03 and 0.01 respectively). Big family size of children suffering anemia and night blindness had reduced their share of energy, protein, iron and vitamin A. The authors suggested some recommendations to alleviate these two diseases in Khartoum State.
Key words: anemia, night blindness, malnutrition, poverty, illiteracy, lactation, low food quality, Khartoum State
Areas nutritionally insecure in Sudan include rural areas of low crop and animal production; areas of low purchasing power and education and knowledge; and areas of low access to health facilities, in addition to areas with low access to water especially during dry season, vulnerable residents who were indirectly affected by the influx of internally displaced population in their communities and returnees numbering 4 million internally displaced population and 600,000 refugees almost all from south Sudan
(FAO/WFP, 2006; Cambrez et al., 1998). Nutrition insecurity leads to protein – energy malnutrition.
Nutrition status is measured directly by dietary surveys, biochemical data, and clinical examination methods. While food adequacy is necessary for a household to achieve nutrition security, it is not in itself sufficient. This is because some other key contributors to good nutrition are also important, such as poverty reduction, female education and a healthy environment. However, some researchers view poverty as the main cause of malnutrition while some others believe in malnutrition eradication without reduction in poverty pointing to well nourished children living in very poor households. Female education is positively correlated with reduction in
1. INTRODUCTION
Nutrition deficiency diseases are worldwide spreading. In Sudan, one child out of ten dies before completing five years due to these diseases (UNICEF,
2008). Malnutrition due to micro nutrients deficiency
(hidden hunger) represents the most prevailing form of nutrition deficiency diseases where more than two billions are suffering from it in the world; in addition to more than 250,000 children are affected by night blindness every year and more than half of these children dies approximately (UNICEF, 2008). In
Sudan, the estimated rate of prevalence of hidden hunger is 4.8% while the rate of anemia (iron deficiency anemia) for children less than five years old is about 55.1% (National Ministry of Health,
2008; World Health Organization, 2009). In
Khartoum State, anemia due to Iron deficiency is distributed as 76% in Khartoum town, 75.3% in
Khartoum north town, and 23.9% in Omdurman town
(National Ministry of Health, 2008; World Health
Organization, 2009). However, nutritional deficiency diseases as cause of death during early childhood, have contributed around 51% among overall causes of death during this period (UNICEF, 2008).
189
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
infant mortality rate (UNICEF, 1990; Brahman,
1988). Environmental health largely determines nutritional status either through infections, depletion of nutrients and illnesses or vice versa (United Nation
University, 1979; Osmani, 1997; Biesel, 1984).
The purpose of this research is to investigate factors influencing nutritional status of children suffering anemia and night blindness in Khartoum
State and to suggest some recommendations to reduce the incidence of these two diseases.
Rate of population increase in Greater Khartoum was
4.92% in 1956, 7.76% in 1973, 8.75% in 1983, and
13.7% in 1993 (MFEP 1956–1993). The number of persons per square kilometer was 55.6 persons in
1973, 85.5 in 1983 and 169 in 1993. In addition
Khartoum state accepted 39% of internal migration of the country in 1983 and 45% in 1993 (MFEP 1956 –
1993). This population increase is reflected in the expansion of informal squatter areas (El Bushra,
1995) and consequently higher demand for public services. 2. MATERIALS AND METHODS
2.1. THE STUDY AREA
Khartoum States consists of the three towns of
Khartoum, Khartoum north and Omdurman (Fig.1).
Fig. 1: location of the three hospitals under study in Khartoum State
Khartoum State (Ministry of Health Khartoum
State,2009), the formula provided by Ministry of
Health, Khartoum State 2009, was used below:
2.2. Data collection
The fieldwork took place in February 2009 through to
February 2012 in central specialized children hospitals in each of the three towns, including Ga’far Bin Oaf
Hospital in Khartoum, Child Emergency Outpatient of
Omdurman Hospital, and Ahmad Grasim Hospital in
Khartoum north. A questionnaire was designed to collect relevant nutritional data of children suffering anemia and night blindness, as well as clinical data on symptoms of anaemia and night blindness. To estimate the sample size, based on 10% rate of prevalence of nutritional deficiency diseases in
n = sample size;
Z = 1.96; P = prevalence rate of nutritional deficiency diseases; q = 1 – P; d
= 0.05
The 10% prevalence, n (1.96) e rate of nutritional deficiency diseases in Khartoum State is used to get q which gave 138 individuals, as follows:
190
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
n= (1.96)2 x 0.1(1-0.1)
(0.05)2
=
To determine the share of each Hospital from this sample size, the equation of distribution in proportion to size of population (children suffering nutritional
= 138 deficiency diseases) in each hospital is used, as follows: Cases of malnutrition in Khartoum (15628) =
100 × 15628
49003
= 32%
Cases of malnutrition in Khartoum north (12602) =
100 × 12602
49003
= 26%
Cases of malnutrition in Omdurman (20773) =
100 × 20773
49003
= 42%
The total cases of malnutrition in Khartoum State = 49003; The share of each town (hospital) of the sample size is determined as:
Khartoum =
138 × 32
100
= 44
Khartoum north =
138 × 26
100
= 36
Omdurman =
138 × 42
100
=58
Before conducting the fieldwork, children suffering anemia and night blindness were determined by testing blood samples which was done by
Technicians working in each of the three hospitals, as well as one of the authors. Symptoms of anemia and night blindness were specified by Doctors during their routine rounds in the hospital. Following that, the questionnaires were filled with mothers of the sick children whom were chosen purposively. Hemoglobin measurement was done by Colorimeter, by taking 20 micro millimeter of the blood of the 138 sick children in a test tube, and 4 milliliter of
Drabakin was added with 14.8 15 gram/deciliter concentration and fully mixed, left for five minutes to be read by Colorimeter. This gave that: Hemoglobin gm/Deciliter X 6.8 (constant factor) = Hemoglobin %
Anthropometric measurements were done using
Salter’s scale to measure weight for age for all the 138 children to determine their nutritional status, where the nutritional status index of weight for age is a quick
and accurate method to determine the nutritional status of children less than five years old.
The evaluation of the nutritional status of children less than five years old was done using tables of estimation of rate by age – group which is published by World Health Organization. The most indices used to measure body to estimate nutritional status is weight for age index. Measurement of weight is used into observing gradual growth in body volume and organs and helps into detection of early malnutrition.
Daily food weight intake was carried out using electronic scale which weights for 3 kilograms. To determine average of energy, protein, iron and
Vitamin consumed relative to the size of the household. Children under study were divided into age groups including less than one year, 1-3 years, and 4- 4.11 years; This classification facilitates comparison between food consumption according to age groups of children less than five years old.
Nutrients intake were calculated using food
191
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
composition tables for population in Sudan, provided by Sukar (1985). Conditions for rejection included all children transferred from other States of Sudan hospitals during fieldwork, and the study was restricted to those who live permanently in Khartoum
State during the time of fieldwork.
Traditional porridge is made by boiling cereals
(Dura or Dukhn), and usually taken with sauce or milk. Sauce is a mixture of vegetables, meat, oil, and spices. In addition, cereals are fermented and cooked to produce traditional bread (Kisra).
USD per day to categorize them as urban poor. The majority of the households (87.7%) did not have an additional income or remittances from their relatives outside Sudan, while 12.3% have additional monthly income that on average is 225 Sudanese Guinea ( 38
USD).
The majority of the houses of the interviewees had traditional pit latrines (82.6%), shared pit latrines with neighbors (13.8%) and modern sewerage system represented very low percentage (1.4%). The highest percent of them have no bathroom (42.0%) and depend on water vendors to get drinking water
(donkey carts) by 47.8%, followed by those who have piped water supply (43.5%), while some others depend on communal water pipes (8.7% ). The majority of the houses have one room (42.0%), followed by two rooms (31.2%), then three (15.2%) and lastly four rooms (11.6%). These rooms range in area where small rooms 12 m2 represents the highest percentage (59.4%), followed by 16 m2 (38.4%), and lastly 9 m2 (2.2%). They depend on natural ventilation
(73.9%), and range in number of windows per room where, 4 windows dominated (43.5%), followed by three windows (33.3%), and 2 windows (16.7%) and one window (6.5%).
3. RESULTS
3.1. Socioeconomic characteristics
The results of the fieldwork depicted that 94.2% of the mothers interviewed were married, 4.3% widowed, and 1.4% divorced. The age structure of the households depicts that, the age group of children less than one year old represents 6.1%, and the age group
1-3 years represents 18.7%, while the age group 4-6 years represents 13.0%. They collectively represented
37.8% of the total number of the members of households. The remaining percentage is distributed among the other age groups where the age group 29+ holds 24.5% of the total number of members of households. The population is young, and its pyramid would be flat at the bottom and had hard tip on top.
Concerning level of education of mothers and fathers of the sick children, results revealed dominance of religious education by 45% among mothers and 23% among fathers, and 35 % of mothers had completed basic school compared to 40% among fathers, while
11% of fathers had completed secondary school compared to 3% for mothers. Generally, fathers are more educated than mothers. Religious education is a form of informal education and does not qualify for good reading and arithmetic.
The majority of the heads of the households worked in the informal sector (43.5%), followed by those who work as traders (8.7%), then government employees (6.5%), while those who worked as farmers and car drivers have equal percent (6%). This reflected educational qualification of the interviewees who were incompetent to compete for higher carriers, and therefore involved into the daily paid wages informal sector. However, 96.4% of the mothers interviewed were housewives, and only 3.6% of them got involved into informal sector. The average monthly income among those who work in the informal sector is 450 Sudanese Guinea (SDG), while traders can get as high as 700 SDG, government employees 350 SDG and car drivers 600 SDG. They collectively give monthly average income of 563
SDG. This equals almost 100 USD per month or 3.3
3.2. Symptoms of anemia and night blindness
Physical symptoms of anemia are loss of appetite
(8777%), paleness (9375%), and fatigue, eating clay
(29%) and eating snow (279%). The symptoms of night blindness are night blindness (12%); xerophthalmia (20%);
Pinot
spots
(52%);
karatomalacia (12%), and Cornea ulceration (4%).
Hemoglobin measurement for children suffering night blindness (Table1) revealed that children aged 1-3 years old had less hemoglobin concentration compared to those aged less than one year. Table 1 also revealed that children aged 3-5 years old who had equal concentration of hemoglobin. This means that children aged 1-3 year old sufferd Iron deficiency anemia compared to the two other groups. This contrasted anemic children, where children aged 1-3 and 3-5 years old almost had equal concentration of hemoglobin which exceeds that for children aged less than one year old. This means that, children <1 year old were more anemic compared to those aged 1-3, and 3-5 years old.
The general striking feature of distribution of night blindness and anemia among these three age groups was that, each age group had acquired ⅓ of incidence of a disease and the differences might be quite minor.
The distribution of children suffering night blindness by sex by percent of hemoglobin (Table 1) depicted that males had higher level compared to females. This could be also seen for anemia. Children suffered
192
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
anemia and night blindness distributed among different age groups had very low percent of
hemoglobin below 60% standard, confirming for prevalence of
Iron
deficiency anemia. Table 1: Hemoglobin measurement (%) among children suffering Night blindness and Anemia by Age’s sex
Age / sex
Night blindness
Anemia
frequency
%
frequency
%
<1 year
3
37
31
32.2
1-3years
18
34.8
73
38.8
3-5 years
4
37
9
39.1
Males
60
43.5
15
10.9
Female
53
38.4
10
7.2
Total
113
81.9
25
18.1
(Table 3), identified the highest rate among those aged
1-3 year old, followed by <1 year old and lastly by those aged 3-5 years old. This means that acute malnutrition remarkably prevails among children aged
1-3 year old, and significantly differs than the other two age groups, and furthermore, the difference between children aged <1 year old and children aged
3-5 years old is more than doubled. The distribution of malnutrition by sex by age distinguishes males first and then females. Females and males aged 1-3 years suffered most. However, females are generally less malnourished than males with difference of 8.6% between them (Table 3).
3.3. Levels of Iron deficiency malnutrition
Table 2 depicts Iron deficiency malnutrition in
Khartoum state. Acute Iron deficiency malnutrition prevails with significant difference than the other three levels of this type of malnutrition shown in the table. The difference between normal and simple levels of Iron deficiency malnutrition is quite small.
Acute Iron deficiency malnutrition is a reflection of low nutritional status which makes children vulnerable to childhood diseases. The distribution of rate of Iron deficiency malnutrition by age groups of these children suffering these two types of diseases
Table 2: Iron deficiency malnutrition of children <5 years in Khartoum State
Iron deficiency malnutrition
frequency
%
Normal
Simple
Medium
Acute
Total
11
13
27
87
138
8.0
9.4
19.6
63.0
100.0
Note: These levels were determined according to weight for age of children suffering these two diseases in Khartoum State.
no noticeable difference in food types during pregnancy and lactation, except the introduction of sweet porridge. Sweet porridge is a mixture of cereals, sugar, oil, and ghee which activates producing much milk for lactating mothers.
Table 5 depicts that, the majority of mothers did not take preventive or curative doses of Vitamin A during pregnancy. This situation is somehow reversed concerning Iron and Fevol. Folic acid recorded the worst position among these four protective elements.
3.4. Type of food during pregnancy and lactation
Table 4 depicts types of type of food during pregnancy and lactation. During pregnancy, mothers used to consume vegetables, fruits, milk, cereals, meat, and legumes abundantly. They also depended on porridge with sauce; salad and yogurt which are connected with likes and dislikes of pregnant women.
Lactating mothers largely depended on vegetables, legumes, meat, cereals, milk, and fruits + sweet porridge which are nutritionally valuable providing protein, energy, iron, minerals, and vitamins. There is
193
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
Table 3: Iron deficiency malnutrition by sex / age
Table 4: Types of foods during pregnancy and lactation (%)
Types of foods
Porridge with sauce
Salad
Salad with yogurt
Vegetables, legumes, meat, cereals, milk, and fruits
Vegetables, legumes, meat, cereals, milk, and fruits+ sweet porridge
Total
Pregnancy (%)
20.3
10.9
9.4
56.4
0.0
100
Lactation (%)
0.0
0.0
0.0
18.1
81.9
100
Table 5: Ante-Natal Drugs Given to Mothers of Night blindness and Anemic Children in Khartoum State
Drugs taken during Pregnancy/
Responses.
Yes
No
total
Vitamin A preventive Frequency
16
118
134
%
Curative frequency 11.6
85.5
97.1
4
118
122
%
Iron
Curative
frequency
2.9
85.5
88.4
47
91
138
%
others
Folic Acid frequency %
Fevol frequency %
34.1
65.9
100
2
134
138
29
109
138
21
79.0
100
2.9
97.1
100
with supplementary food, and 10.9% give their children supplementary food only. This means that, the majority of mothers did not change their behavioral pattern of feeding their children throughout the first year of a child life. However, children prefer biscuits (14.3%), soft drinks (25.4%), and chips
(12.3%), juice (9.4%), cakes (5.8%), and sweets
(8.6%) as supplementary food types. This indicates to shift from traditional food types to ready - made food among urban households. The majority of children
(63.8%) take three meals a day, 21.9% take four meals a day, 2.9% take more than four meals a day, and
11.6% take two meals a day. The majorities of the households share the same dish (84.8%), or eats separately (15.2%).
Table 6 depicts average daily intake of energy, protein, iron, and vitamin A among children suffering anemia and night blindness. From the table, children aged less than one year old ranked first in energy intake compared to other two groups of 1-3, and 4-6 year old. Taking two age groups of children together, children aged <1 year old + 4 - 6 years old ranked first and followed by those aged <1 + 1- 3 years, with very small difference between them.
3.5. Food type of children suffering anemia and night blindness
The majority of households depend on fathers (63.8%) for food provisioning, while few households depend on mothers (10.1%), or relatives (26.1%). The majority of the mothers (61.6%) perceive that breast feeding is important and prevents childhood diseases, while some others (38.4%) ignore that. However,
97.1% of the mothers commence breastfeeding 3 days after delivery. The average period of breast feeding is eleven months. Mothers who did not breast feed their children; have attributed that to death of a mother
(25%), infection of mother with tuberculosis or psychiatric diseases (50%), or the child being sick
(25%).
During the early 6 months of a new born baby,
89.9% of the mothers used to breast feed their children and give supplementary food, while few mothers (7.2%) exclusively breastfeed, and still very few mothers (2.9%) wholly depend on supplementary food. During the second half of the first year of a child
(6 - 12 months), very few mothers (0.41%) depend on breast feeding as the main source of feeding their children, while 87.7% of them combine breast feeding
194
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
Taking daily protein intake by age group of these sick children, children aged less than 1 year old ranked first, followed by 4-6 year old, and lastly 1- 3 year old. Taking two age groups together, had ranked children aged <1 year old + 4-6 years old first, and those aged 1 + 1- 3 years old second, while children aged 1-3 + 4-6 came lastly. The general average intake of protein for the three age groups reveals low
protein intake among children aged less than five years old in Khartoum State. Moreover, ranking daily intake of iron by age groups of these sick children puts children aged <1 year old first, 4-6 year second, and 1-3 year old last. There is slight difference in daily iron intake when two age groups of children are taken together. This is more particular to children in the age groups of <1 + 1- 3 and 1-3 + 4-6 years old.
Table 6: Average daily intake of energy, protein, iron, vitamin A by age among children suffering anemia and night blindness
Age groups
<1
1-3
4-6
<1 + 1- 3
<1 + 4-6
1-3 + 4-6
<1 + 1-3 +4-6
No.
50
153
106
66
74
176
76
Energy (calorie)
1127777
854273
975676
547670
548473
490076
371574
Protein (g)
32675
24877
27974
15575
15977
14070
10677
Table 7 depicts average hemoglobin measurement by age groups of children by daily intake of animal and plant protein. Highest percent of hemoglobin among children aged less than one year old is coincided with highest levels of animal and plant protein intake. This is similarly seen among children aged 4-6 year old. Taking two age groups together had ranked children aged -1 + 4 - 6 year old first, and followed by children aged -1 + 1-3 year old children, with very small difference between them. Increasing
Iron (milligram)
5376
4070
4577
2577
2675
2277
1775
Vitamin A (microgram)
123977
85870
97977
53474
63879
46278
36674
hemoglobin is associated with increasing protein, confirming for better nutritional status of these children. However, the general average of hemoglobin, as well as the general average of both types of protein is far below the recommended levels for children to remain healthy. The fact here is that, an increase in consumption of legumes will reduce Iron absorption due to Fianite and Vitamin C which reduces blood hemoglobin.
Table 7: Average hemoglobin measurement (%) and daily intake of animal and plant protein among children suffering anemia and night blindness by age groups
higher level of energy; protein; iron; and vitamin intake, as well as consumption of better quality protein, with increasing income. Less income will of course result in prevalence of anemia and night blindness in the study area. However, the relationship between nutritional status of children suffering anemia and night blindness and type of food of a mother
3.6. Factors influencing children suffering anemia and night blindness
Table 8 depicts highly significant probability confirming the relationship between household monthly income and number of meals a child takes per day. This implies increased food expenditure and
195
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
during pregnancy gave highly significant probability
(Table 8). The food types during pregnancy (table 4) reflect household monthly income level, educational
attainment, and other socioeconomic characteristics of the surveyed households in the study area.
Table 8: Chi-Square test for relationships between some socioeconomic factors and nutritional status of children suffering anemia and night blindness in Khartoum State
The relationship between sex and age structure of children suffering anemia and night blindness and frequency of daily intake of bread and cereals (P =
0.0008), milk and milk products (P= 0.0008); legumes
(P = 0.0007); vegetables (P = 0.0001); fruits (P =
0.0005); and other food types (p = 0.0004); are positive and highly statistically significant which suggests for influence of food nutrients on anemia and night blindness during early childhood. There is highly significant relationship between nutritional status of children suffering anemia and night blindness and number of children under five year old in the household (P= 0.0002). This points out to decreasing food nutrients intake with increasing number of persons sharing the common dish which its protein content was originally low. This is further
depicted by the relationship between nutritional status of these sick children and ideal method for food distribution in the family (P = 0.027). Since energy and protein intakes (Table 6) were less and the households are big enough, it is expected to have positive relationship between household size and nutrition status of these sick children. In addition, relationship between hemoglobin level (%) and amounts of animal protein consumed is positively statistically significant (P= 0.01); and similarly with plant protein (P= 0.03).
However, other factors influencing nutrition status of children less than 5 years old in the study area might include those operating at the national level.
They are financial inflation and corruption; absence of social development, insufficient productive capital
196
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
investment in agriculture and industry, lacking development policies that care or rural – urban development and armed conflicts.
less than five years old living in poor urban Khartoum state (Al Jaloudi, 2000). In addition, the difference in malnutrition is possibly due to geographic reasons. In
Khartoum State, squatter areas have expanded rapidly in recent decades, occupied by poorest people who are generally facing inadequate food intake and unhygienic residential environment (Alredaisy and
Davies, 2003, Babiker and Alredaisy, 1997).
However, since the majority of mothers did not take preventive or curative doses of Vitamin A during pregnancy (Table 5), this makes mothers and new born infants vulnerable to many childhood diseases.
However, this situation might be milder when putting into consideration that 61% of the mothers have been vaccinated, 32% partially vaccinated, and only 7% were not vaccinated. The general average intake of energy for the three age groups reveals low energy
(calories) intake among children aged less than five year old in Khartoum State. The general average of daily iron intake depicts very low level among these children. This picture is also seen when daily intake of
Vitamin A is taken into consideration.
Average daily intake of energy, protein, iron, and vitamin A by age groups of children suffering anemia and night blindness had identified children aged less than one year as the most advantageous group compared to the other two groups. In addition, the general average of each of these nutrients is far below the recommended level for children to remain healthy in Arica and Sudan. Comparing macronutrients daily intake in the study area (Table 6) with the study by
Ministry of Agriculture and Forestry of Sudan (FSU,
2005) puts the study area below by that there are less protein, carbohydrates and lower energy intakes.
There is less animal protein; vitamins, minerals consumed and abundant cereal are consumed. In the study area, fat and carbohydrates (calories) consumed were lower than the recommended values (Katch,
1983) and for population in Africa which is 2041.7 calories (Latham, 1997). This study agrees with
Mohammed's study in Al Shigla area in east
Khartoum State, which indicated to imbalanced intake of food types where legumes and cereals are abundantly consumed while meat, fish and chickens are less consumed among surveyed households
(Mohamed, 1999). It also agrees with Ali's study in north state of Sudan where cereals are the main source for poor households although cereals are deficient in vitamin A, and 41% of the sample suffers vitamin A deficiency (Ali, 2005). Energy obtained by higher protein and carbohydrates intakes was more than double the value obtained by excess fat intake in this study (FSU, 2005). Cereals highly contribute to energy and protein intake in the study area, a situation similar to rural Philippines where 361g/person/day are consumed there (Florentino, 1996). Animal protein
4. DISCUSSION
The investigation of nutritional status of children suffering anemia and night blindness in Khartoum
State suggests low hemoglobin rate; inadequate food intake and prevalence of malnutrition by age and sex with major and minor differences. Males suffering anemia and night blindness are more malnourished compared to females. This agrees with the fact that, generally children suffer night blindness between second and fifth year of childhood, with more emphasis to males than females, but differs concerning anemia which prevails more between 6 to
8 months of a childhood, but with more emphasis to males than females (Hassan et al., 2002). The high rate of hemoglobin concentration among children aged less than 1 year old might be attributed to more care given to a lactating mother in Sudanese culture which effectively supports neonatal period and early childhood, where relatives could supply with nutritional food types such as sweet porridge.
Children aged 1-3 year old have less hemoglobin concentration and suffers Iron deficiency anemia compared to the two other two groups. This might be attributed to average short period of parities and to poverty which make the majority of Sudanese to afford living costs in situations of accelerating financial inflation. However, prevalence of breast feeding in the study area is attributed to the awareness of mothers to its nutritional value to a newborn child, and to the inherited Islamic culture which enhances mothers to breast feed their children for two complete years. It might be also attributed to the fact the majority of urban households are incapable to purchase readymade food for their children where 70 to 80% of urban population live below the poverty line (Hamid, 2000), and also many of the mothers are mainly housewives who have devoted themselves to child bearing. However, this is supported by the fact that, during pregnancy and lactation, mothers used to consume vegetables, fruits, milk, cereals, meat, and legumes abundantly compared to less amounts of these food types during lactation.
Prevalence of low weight and malnutrition among children less than 5 years old in Khartoum State
(Table 2) is almost similar to the 50 % cited by FAO and WFP for pre-2001 studies for North Kordofan state (FAO/WFP, 2006). However, it was higher than the most recent report Sudan household health survey of 42.9% (SHHA, 2006). The result was also higher than all previous studies carried out in Sudan, although it is similar to that by Al Jaloudi for children
197
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
sources such as meat and milk provide less than the recommended value which is 55.3g (FSU, 2005).
The high fertility rate of population of the study area agrees with general demographic trends in Sudan where total fertility rate was 5.9 births per woman in
1999; annual population growth rate was 2.53 % between 2003 and 2007 and the natural rate of increase was 41.23 per 1 000 in 2006 (Ministry of
Health, Sudan. 2008). Dominance of Low income groups in the study area agrees with figures in Sub–
Saharan Africa where about half the population is living below the poverty line, with both numbers and percentage on the increase (Alredaisy, et al., 2001).
Generally, growth of towns and cities in Sudan has been accompanied by growing numbers of poor and vulnerable urban dwellers (Sara Pavanello, 2011).
Although Sudan is rich in natural and human resources, 77.5% of the households surveyed in north
Sudan were on or below the poverty line (MOL and
ILO, 1997]. The study by the United Nations
Development Program in 2005 reported that 75% of north Sudan population as poor and the majority
(80%) is concentrating in rural areas where 30% of them suffered from extreme poverty (United Nations
Development Program, 2005). The majority of the urban poor are dependent upon marginal livelihood activities in the informal economy, and their access to safe and sustainable livelihoods is extremely unstable
(Sara Pavanello, 2011). However, factors influencing income attainment in the study area might include those operating at the national level including absence of social development and insufficient productive capital investment (UNDP, 1998), ill-conceived development policies and armed conflicts (Zeng,
2003).
Fieldwork results depicted positive relationship between number of meals a child takes per day and household monthly income (table 8). Some researchers are convinced that increasing income leads to increasing food intake (Strauss 1984,
Maxwell et al 2000) while some others believe that poor households spend their additional incomes on more expensive foods such as finer cereals, meat or dairy products which do not necessarily yield more energy. The fieldwork results support the first assumption that increasing income had positively increased number of meals a child takes per day and therefore more energy and protein intakes are expected. Less income resulted in prevalence of malnutrition in the study area, thus decreasing income might lead to marginal or sub-optimal intakes of energy and protein resulting in more prevalence of anemia and night blindness. In addition, it is expected that more energy and protein will positively correlate with three meals per day other than with two meals.
Higher level of protein intake implies consumption of
better quality protein with increasing income. There is significant increase in energy and protein intakes with increasing incomes and a similar increase that was highly significant were recorded for protein (Ibrahim,
2008). Many studies in Sudan referred low weight among young children to unequal income distribution, vertically between incomes and horizontally between rural and urban areas (UNDP 2006). Furthermore, increased income will increase food expenditure in the study area as has been confirmed in rural western
Kordofan State (Alredaisy and Suleiman, 2011) that had significantly increased energy and protein intakes in the study area for both energy, probability of 0.042, and for protein with probability of 0.025, and significant relationship exists between food expenditure and undernutrition prevalence in the study area with probability of 0.004.
The relationship between nutritional status of children and type of food consumed during pregnancy is highly significant (0.0056). This might be attributed to household monthly income, educational level of a mother or a father where the majority has attained religious or basic education. Mothers' literacy positively effects low weight- for- age compared to illiterate mothers who have more stunted children in
Sudan (FAO/WFP, 2006), and in Khartoum State
(Magboul et al, 2000) and SERISS (1988) and SMCH
(1995) results where mothers' educational level was remarkably influential.
One of the main reasons for generally declining levels of food consumption in the study area is attributed mainly to the high living costs and high inflation rates in Sudan. The high expenditure on food in situations of low income, big households and illiteracy has many consequences. One consequence is that, a low-income household's consumer surplus for food is very high, amounting to a substantial proportion of its total income. This has important consequences for the economic appraisal of food supply. With regard to affordability, households are unable to pay for food at the current cost. High proportion would be unable to pay the actual costs of food. The revenue that may realistically be expected to be recovered from these households in the future lies somewhere between what they are able to pay and what they are presently willing to pay. Another consequence is the lack of elasticity and repercussions on expenditure for food would imperatively be retarded. The high price of food in urban Sudan is probably a major cause of the malnutrition prevalent in the squatter areas (Sandy et al, 1992). Decreasing income led to marginal or sub-optimal intakes of energy and protein resulting in more prevalence of under-nutrition in rural western Kordofan of Sudan
(Alredaisy and Suleiman, 2010). Many studies in
Sudan referred low weight, stunting and wasting
198
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
among young children to unequal income distribution, vertically between incomes and horizontally between rural and urban areas (UNDP, 2006).
Ali AM (2005). Vitamin A deficiency and nutritional status among basic schools students in Dongola town. M Sc. University of Khartoum.
Alredaisy SMA, Sulieman HI (2011). Assessment of nutritional status of children less than 10 years old in rural Western Kordofan, Sudan’’. An
International Journal of Multidisciplinary
Integrative Science and Applications. India.
IIOAB Journal 2 (4): 40-49.
Alredaisy SMA, Davies HRJ (2001). Food insecurity in Sub-Saharan rainlands: Um Sial, a village in
White Nile state, Sudan. The Arab World
Geographer, 3(1): 19–30.
Alredaisy SMA, Davies HRJ (2003). The ecology of malaria in urban squatters of Greater Khartoum,
Gamier area in Omdurman. Arab World
Geographer Journal, 6(3): 178-193, Canada.
Babiker A, Bagi A, Ghani, Alredaisy SMA (1997).
Evaluation of food situation and survival strategies in urban Sudan, case studies from
Omdurman. Bayreuther Geowissenschaftliche
Arbeiten, 16: 291-300. Germany.
Biesel WR (1984). The metabolic effects of infection.
Progress in Food. Nutr Sci 8:43–5.
Brahman GNV (1988). Intra family distribution of dietary energy- an Indian experience. Ecol of
Food Nutr., 22: 56–64.
Cambrez C, El Magboul B 1.1998. Food security and nutrition situation in north Sudan. FAO/WFO
Crop assessment mission for Sudan. Khartoum,
Sudan.
El Bushra, El Sayed (1995). Two Million Squatter
Settlements in Khartoum Urban Complex. The
Dilemma of
Sudan National Capital
GeoJournal, 34(4): 505-514.
FAO/WFP (2006). Special report, crop and food supply. Assessment mission to Sudan, 827/10/2005, FAO, Rome.
FAO/WFP (2006). Special report, crop and food supply. Assessment mission to Sudan, 8–
27/10/2005, FAO, Rome.
Florentino RF (1996). Contribution of major food items on calorie and protein in takes in
Filipinos. Joint technical workshop of the micro impacts of macroeconomics adjustment policies and the Philippine Institute of Development
Studies technical resources project, 1112/4/1996, Calatagen, Phillip.
FSU (2005). Food security annual report. Food
Security Unit, Ministry of Agriculture and
Forestry, Khartoum, Sudan.
Hamid GM (2000). Local level authorities and local action in Greater Khartoum. The Arab World
Geographer 3:230-48.
Hassan S, Hindi H (2002). Human Nutrition. First
Edition, Alexandria, Egypt (Arabic).
5. CONCLUSION AND RECOMMENDATIONS
The general conclusions of this study are as follows:
1- Children aged less than five year old living in
Khartoum State are suffering anemia and night blindness. 2- Malnutrition and underweight are prevalent in
Khartoum State.
3- Promotion of community and child nutrition is a necessity in the study area.
4- Many interrelated socioeconomic factors are influencing anemia and night blindness.
5- Promotion of child nutrition and urban living conditions is a necessity in the study to combat these two diseases.
Based on that, some suggestions could be presented. Firstly, breast feeding should be enhanced from delivery up to six months of a child’s age, and should be accompanied by supplementary feeding thereafter up to the completion of two years of a child age. Secondly, more care should be devoted to qualitative and quantitative complementary feeding.
Thirdly, introduction of balance diets rich in vitamin
A, and Iron when a child completes six months of age, and during pregnancy and lactation is a necessity.
Fourthly, nutrition education should be introduced and enhanced among mothers to accept knowledge about good child feeding. Fifthly, urban poor should be supported by appropriate socioeconomic development programs to curb financial inflation which adversely depriving this segment of the society. Promotion of urban living conditions could be through provisioning adequate housing conditions; income generation sources to poor urban households; stopping accelerated financial inflation; and reducing rates of rural - urban migration to avoid addition of more urban poor and growth of squatter settlements. In addition, Sudan has to work hardly to solve political problems with South Sudan Republic and the rebelling militia in Darfur, southern Kordofan, and
Blue Nile to achieve stability that will reflect on development of agriculture and industry that will certainly promote nutrition status of the young growing generations of Sudanese youth.
REFERENCES
Al Jaloudi AE (2000). Assessment of the nutritional status and household food security in the poor urban areas in Khartoum state: case study
‘’Marzouk in Omdurman’’. Unpub. PhD.
Thesis, University of Khartoum, Sudan.
199
Alredaisy and Saeed
Factors Influencing Anemia and Night Blindness among Children Less than Five Years Old (0 - 4.11 Years) in
Khartoum State, Sudan
Ibrahim HS (2008). Poverty, food security and malnutrition in an urban – rural setting: case study the former west Kordofan state.
Unpublished PhD thesis, University of
Khartoum.
Katch F (1983). In nutrition, weight control and exercise. 2 nd edition, Lea and Bebiger,
Philadelphia.
Latham, H C (1979). Human nutrition in tropical
Africa. No.11. Rev.1. RAR. Rome. Ithaca.
USA.
Magboul BI, Mohammad KA, El Khalifa MY (2002).
Dietary iron intake and prevalence of iron deficiency anemia among underfive children in
Khartoum state. Report to EMRO/WHO,
Project EM/ICP/RPS/002.
Maxwell D (2000). Urban livelihoods and food nutrition security in Greater Acccra, Ghana.
IFPRI/Noguchi Memorial Institute for Medical
Research/WHO. Accra, Ghana.
Ministry of Finance & Economic Planning, MFEP
1956-1993: Population censuses of Sudan 1956
– 1993, Khartoum, Sudan.
Ministry of Health, Sudan (2008). Annual health statistics report: Health statistics. Khartoum:
National Center for Health Statistics.
Ministry of Labor and International Labor
Organization (MOL/ILO )(1997). Trends and profiles of poverty in Sudan [1990–2008].
Ministry of Labor and International Labor
Organization, Khartoum.
Mohammed, F O (1999). Iron deficiency anemia among children less than five year old in
Alshigla area, Khartoum State. MSc. University of Khartoum.
National Ministry of Health (2008). Guidelines for combating micronutrients deficiency. National
Ministry of Health, Khartoum (Arabic).
Osmani SR (1997). Poverty and nutrition in south
Asia. ACC/SCN Symposium, Katmandu,
March 1997. Nutrition Policy Report 16: 23–
51.
Sandy C, Kinnear J (1992). Elasticity of demand for water in Khartoum, Sudan, Social Science &
Medicine, Volume 34, Issue 2, Pages 183-189
Sara Pavanello (2011). Urbanization in Sudan: An
Overview of International Engagement http://www.refugeecooperat SERISS Sudan emergency and recovery information and surveillance. 1988. Ministry of Health,
Directorate of primary health care/ nutrition
Department,
Department of Statistics.
Workshop, Friendship Hall, 22-25 Feb.,
Khartoum, Sudan.
SHHA (2006). Sudan household health survey.
National report, Government of Sudan,
WFP/UNEFPA/WHO/USAID/UNICEF,
Khartoum, Sudan.
SMCHS Sudan maternity and child health survey
(1995). Ministry of Health, Khartoum, Sudan.
Strauss J (1984). Joint determination of food consumption and production in rural Sierra
Leone, estimate of a household mode. Journal of Develop. Econ., 14:19-103.
Sukkar MY (1985). In human nutrition. Khartoum,
Sudan.
United Nations Development Program (2006).
Macroeconomic policies for poverty reduction, the case of Sudan. October 2008, Khartoum.
United Nations Development Program (2006).
Macroeconomic policies for poverty reduction, the case of Sudan. Khartoum.
United Nations Development Program (1998). SudanCommon Country Assessment. UNDP,
Khartoum.
UNICEF (2008). Nutrition. www. UNICEF. org/Arabic. UNICEF (1990). Strategy for improved nutrition of children and women in Developing Countries.
UNICEF, New York.
United Nation University ‘’UNU’’ (1979). The nutritional consequences of acute and chronic infections. Protein energy requirements under conditions prevailing in Developing Countries: current knowledge and research needs. Food
Nutr Bull S, (1): Tokyo.
United Nations Development Program (2005). Human development report. Oxford University Press,
Oxford.
United Nations (1977). Desertification: its causes and consequences. Pergamon, Oxford.
World Health Organization (2009). Guidelines for combating micronutrients deficiency. WHO.
Geneva.
Zeng N (2003). Drought in the Sahel. Science, 302:
999–1000.
200
International Journal of Scientific Research in Knowledge (IJSRK), 1(7), pp. 189-201, 2013
Samir Mohamd Ali Hassan Alredaisy is Associate Professor at University of Khartoum. He received his first degree from University of Khartoum in 1983/ He obtained Masters from University of Khartoum, and PhD from University of Wales, Swansea in 1993. His current research focuses on Medical
Geography of Sudan. To date, he published more than 40 referred papers, and 20 textbook and reference. Haram Omer ELHag Seed is a Nutritionist at Health Unit in Central State (Gezira) in Sudan. She obtained her first degree in nutrition from Ahad University and her Masters in Science from University of Khartoum. To date, she published two referred papers. Her current research focuses on nutrition problems in Gezira area, particularly among prgnat mothers and newborn children.
