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Vitamin A deficiency among children from low socio-economic status living in different environments in Khartoum State.

Vitamin A deficiency (VAD) is a major public health problem in Sudan. The disease was hyper-endemic in the East, but during the last decade the country has been passing through difficult times and continuous changing situations, where the civil war in the south, the emergency of drought and desertification, then the rains and floods ended with a food gap which led to the spread of vitamin A deficiency nearly all over the country.

This study was a cross-sectional study using motherhood method for collecting data. The study was conducted among 160 mothers having 295 children in the age groups between 6 months--10 years in four groups of low socio-economic status. Two of thegroups were living in urban slums (Daralsalam and Alsemeir) and the other two groups were living in pockets with populations of low socio-economic status within areas of high socio-economic status (Alryad and Shambat New Extension).

The data was collected by interviewing the mothers using standardized administrated questionnaires where night blindness and occular abnormalities were used as the criteria for diagnosing the disease. Anthropometric measurements were also used to determine the general nutritional status of the populations. The prevalence of VAD in the four areas was: 59% at Daralsalam, 38% at Alsemeir, 49% at Alryad and 32% at Shambat based on occular abnormalities. Night blindness was 23% at Daralsalam, 6% at Alsemeir, 8% at Shambat and no single case in Alryad. Vitamin A deficiency in children was associated with insufficient dietary intake and attacks of infectious diseases (diarrhea, measles and respiratory infections). Mother's low educational status and lack of nutritional education played an important role in the spread of the diseases and thus health education was highly recommended for the mothers of malnourished children to avoid consequences of VA depletion. In this study it was thought pertinent also to confirm the recommendations of Mohamed, M. and Hassan, S. (2) that VA supplementation programs should continue fill the economic crisis is solved. Also nation wide surveys are necessary to determine the exact prevalence of VAD to launch the necessary interventions.

The study put in evidence that the residential area is a very important factor in nutritional status; food support from surroundings depended on the area of living (p=0.000). Alryad is the area where the support is more frequent compared with Shambat (table 5), while nutritional status of children is significantly different, ([X.sup.2] =29.408), in such a way that 64% of children in shambat were well nourished compared with the children in the other three areas, 41% from Daralsalam. 38% from Alsemeir, and 32% from Alryad (table 8).

Inspite of support; Alryad area revealed a bad status of nutrition for children compared to Shambat where the support is less and this may be due to many factors such as: the supportive food taken only by the elders, or the supportive food is not regular, although the quality of the supportive food in Alryad contains vegetables and fruits. Receiving VA supplement, as well is signifcantly different ([X.sup.2] = 69. 084); in Darasalam 90% compared with the other three areas where 77% were from Alsemeir, 59% from Shambat, and 32% from Alryad.

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Introduction

Vitamin A deficiency (VAD) occurs largely in developing countries among undemourished children whose diets are limited in carotene containing vegetables, animal products ,and fat. Very often repeated episodes of diarrhea and other infections interfere with absorption, and increase vitamin A (VA) requirements. Febrile illness and particularly measles may precipitate keratomalacia in subjects with depleted vitamin A stores. In global surveys sponsored by World Health Organization (WHO), it was found that vitamin A deficiency was a cause of blindness, in varying degrees in all the 30 countries in South East Asia, Africa, and Latin America visited by the team (1)

Vitamin A continues to be a leading cause of micronutrient deficiency, blindness, and eye disorders in the Philippines. In 1992 the study done by UNICEF, among children six months to six years of age, the prevalence of night blindness was 0.7% and of Bitot's Spots 0.2%. Certain communities (remote rural villages, urban slums) and population groups (children from large families, with poorly educated mothers, from unlanded farms or small fishing households) are considered at higher risk than others (4).

Vitamin A deficiency in Sudan

In Sudan, vitamin A is considered as a public health problem. The surveys that were conducted in Khartoum and Gezira (1982) indicated that vitamin A deficiency prevalence was 2% (2). Recent studies conducted in the urban slums of Khartoum state in 1994, have shown that vitamin A deficiency in children was 46.3% at Wad Elbashir (3). A more recent study (1999) carried in Daralsalam and AlSemeir urban slums around Khartoum ill children aged 6 months to 6 years found that, the prevalence of VAD in urban slums was 18% at Daralsalam and 29% at Alsemeir. This serious magnitude of prevalence was considered to be an outcome of interrelated socio-economic factors that included, low family income, low education levels and unawareness of the population, irrespective of whether health services were available or not (2)

A collaborative study was conducted in 1978 by the WHO and Nutrition Department in the Gezira and Khartoum areas. There, 1948 boys and 1972 girls were studied. Of those, 1.9% were having both Bitot's Spots and Xerosis, no Corneal Lesions were detected. So according to the WHO criteria, Xerophthalmia does not appear to be a problem of a public health significance in these two provinces. But there were indicators that hypovitaminosis A was fairly prevalent which need to be confirmed by determining serum vitamin A level (5)

In Sudan during 1989 a study was conducted to estimate vitamin A status of well-nourished, breast-feeding Sudanese women in Gezira area. Plasma retinol and total tocopherol were estimated. It was found that neither the retinol nor tocopherol values showed a correlation to parity or duration of breast-feeding (6)

In 1991, a study was conducted in Sudan in Khartoum Teaching Hospital aiming at examining malnourished children for signs of Xerophthalmia. It was found that 29% of the study group (4moths-5years) had varying degrees of Xerophthalmia. These included 56% Bitot's Spots with Conjuntival Xerosis, 11% with Corneal Ulceration, 17% with Bitot's Spots, 1% with Corneal Xernsis and 3% with Corneal Scars, and 9% were having night blindness (7).

In 1997, a study was conducted in six Sudanese states (Kassala, South Darfur, North Kordofan, Red Sea, Gazira and Nahr Elneil). The aims of the study were to evaluate the nutritional status and micronutrients deficiencies including vitamin A of children and mothers. The results showed the overall prevalence of night blindness was 8.5% and was found to be inversely proportional to age of weaning. In the Red Sea Province the study showed that 3.7% of primary school children had Bitot's Spots and 4.81% were having night blindness. The study also revealed high prevalence of vitamin A deficiency particularly in the Eastern part of Sudan (8).

In a more recent study in 1999, the major findings of the study have shown that vitamin A deficiency in urban slums was 18% at Daralsalam and 29% at Alsemeir (2) The study concluded that the situation of VAD in urban slums is alarming because of low income of families, the level of education of parents and complete absence or poor health centers when available. The researchers also made the following main recommendations: fortification of sugar or even other diets, with vitamin A supplements as recently advised by a WHO consultant is unrealistic under our present economic situation. Health education through serious health services, improvement of the income situation of the Sudanese citizens and immediate VA supplementation interventions are of vital importance (2)

Justification

Still studies on vitamin A deficiency in young children, in the Sudan need further investigations and surveys for authentic documentation and suggestions on possible solutions. Again all studies conducted were restricted to the age group of children between 6 months and 5 years. All such investigation were conducted in areas with low socio-economic status and poor or lack of health services. So far, no investigations were carried out in areas with pockets of populations with low socioeconomic status riving amongst communities of high socio-economic status.

Objectives:

1) To estimate the prevalence of vitamin deficiency among children between 6 months and 10 years old riving in urban slums.

2) To study vitamin A deficiency of the same target group of low socio-economic status living in residential pockets among populations of high socio-economic status.

3) To assess the perception of mothers towards the problem.

4) To further knowledge on the relationship between dietary factors and infectious diseases to vitamin A deficiency.

5) To verify whether there is an association of vitamin A deficiency with educational awareness, and socio-economic status of the studied target groups.

Methodology

The study was a cross-sectional study using motherhood method for collecting data.

Population

The study was conducted on children between 6 months and 10 years of age, The elementary unit of analysis was a child between 6 months and 10 years of age.

Study areas

Four areas were chosen: Daralsalam, one of Omdurman Urban Slums, was chosen randomly from a list of slum areas that were found registered in the Ministry of Health (MOH). Daralslam urban slum is situated approximately 25km outside Khartoum State and 14km South Libya Market. Tribes riving in Daralslam Omdurman urban slum were Deinka, Nueir, Shuluk, Nuba and Kordofan Arabs. Alsemeir urban slum, is a new settlement which is neither registered in the Ministry of Health nor in the Ministry of Housing Alsemeir urban slum is situated south West Soba about 30km from Khartoum centre, and it is divided into two parts:

Alsemeir Almahatta and Alsemeir Alhila. The investigation was done in Alsemeir Almahatta. Tribes living in Alsemier were Bargo and Tama (originally from boarders between Sudan and Chad). The other two target groups represented populations of low socio-economic status living in subhuman residential pockets in Alryad and Shambat New Extension. The latter are two areas populated with citizens of very high socio-economic status.

Sample size

According-to the literature and statistical method for calculating sample size the equation: N = [2.sup.2]Pq/[d.sup.2] was adopted, where 2 is normal standard quartile at level of 5%, P is prevalence of vitamin A deficiency; q is 1-P and d is the precision of the study.

The suggested sample was 160 mothers with children whose age varied between 6 months to 10 years.

Definition of variables

The dependent variable is vitamin A deficiency and independent variable is the child between 6 months and 10 years of age in the studied area.

Data collection and materials

1) Standardized administered questionnaires and personal interviews were used for mothers

2) Books, journals, reports, etc.

Determination of VAD was based on dietary assessment and examining ocular abnormalities.

Criteria of exclusion

Mother without children.

Data analysis

Qualitative statistical analysis was used. Computer facilities and Statistical Package of Social Science (SPSS) was used.

The criteria for determining malnutrition were based on measurements of the body to see if growth has been adequate (anthropometry).

1. Height for age is an indicator of chronic malnutrition. A child exposed to inadequate nutrition for along period of lime will have a reduced growth and therefore a lower height compared to other children of the same age (stunting).

2. Weight for age is a composite indicator of both long-term malnutrition (deficit in height/"stunting").

3. Weight for Height is an indicator of acute malnutrition that tells us if a child is too thin for a given height (wasting).

4. MUAC is another anthropometric indicator. MUAC is simple, fast and is a good predictor of immediate risk of death, and can be used to measure acute malnutrition from 6 months to 59 months.

The degree of malnutrition was evaluated according to the weight for height methods.

Results

Table 1 shows that the daily income of 61% of the studied population was less than 3000 L.S, 33% were in the range 3000-5999, 4% were in the range 6000-8999, while only 2% of the selected sample had daily income that exceeded 9000 L.S.

Table 2 reveals that malaria is the disease that mostly occured (23%), diarrhea came in the second place (22%), respiratory diseases were 15% and measles were 5%. Regarding the combination of diseases, D&M were 16% D&Me were 1% D&R were 6%, M&Me were 2.7%, M&R were 5% and Me&R were 0.3%. However, out of all coach-acted diseases malaria (47%) and diarrhea (45%) were of great prevalence.

Table 3 shows that in Alsemeir 78% of mothers started to give their children weaning food after the 4th months. Whereas the frequency of children whose mothers provided them with weaning food after 4th months was 97% at Shambat, 96% at Alryad and 94% at Daralslam. Those who weaned after more than 9 months ranged from 0-8%, while those who weaned before 4 months ranged from 0-14%.

Table 4 shows that the majority (33 %) of the mothers gave their children SF, 25.5% gave LV + SF, 1.5% gave M&MP, 1.5% gave M & MP + LV, 1.5% gave L+ LV and 0.5% gave L, 0.5% gave LV, 8% gave M & MP+L, 7% gave M& MP +SF, 4% gave L+SF. While 17% gave all types of these food.

Table 5 shows that getting food from surrounding communities was more frequent in Alryad (90%), while Shambat (12%) where the support from surrounding communities was poor (p=0.000).

Table 6 shows that the majority (80%) of food items obtained from surrounding families were mulah and only 20 % obtained mulah + bread from surrounding families. None got meat, vegetables or fruits.

Table 7 shows that 55.5% of food items obtained from surrounding families were mulah, 25 % obtained vegetables & fruits, while 19.5% obtained mulah +bread and none got meat.

Table 8 Shows that there is a relation between residence and child nutritional state (p= 0.000), in such way that Shambat was the area where 64% of the children were well nourished, while the percentage of the well nourished children dropped to a range that varied from 32-41% in the three remaining areas. The moderately malnourished were 42% at Daralslam, while the percentage in the other three areas varied from 20-28%. Those who were severely malnourished constituted 41% at Alsemeir, 40% at Alryad and in the other two areas ranged from 15-17%.

Table 9 shows that 66% of the mothers did not receive VA supplements during their pregnancy, while 10% of the mothers did and 24% did not know whether they received VA supplements or not.

Table 10 shows that the number of times that the child received VA depends on the area where the child was resident (p=0.000). Children receiving VA supplement were 90% from Daralsalam followed by Alsemeir 77%, 59% at Shambat and 32% at Alryad. Those who received VA only once varied in the four areas from 10-28%. In Alryad 48% of children did not receive VA, Shambat 13%, 8% at Alsemeir while 0 at Daralslam.

Table 29 shows that Shambat was the area where the percentage of VAD was comparatively low (32%), while Daralsalam was the area where VAD was high (59%), Alryad 49% and Alsemeir 38%. At Daralslam 41% did not suffer from VAD, 62 % at Alsemeir, 51% at Alryad and 68% at Shambat.

Table 12 It is clear that Daralsam is the area where the night blindness is more frequent (23%), 8% at Shambat, 6% at Alsemeir and 0 at Alryad.

Discussion, conclusion and recommendations

The daily income of the over whelming majority (98%) of the families was quite low (0-8999 L. S./day) and only 2% had daily income that exceeded 9000 L.S./day (table 7). This may indicate that the low income was not enough to meet basic minimum needs especially foods with nutrients and micronutrients such as vitamin A, whose chronic deficiency leads to night blindness and other health complications. This is in addition to other health hazards through contraction of diseases such as measles, diarrhea and respiratory infections (table 2).

In all four areas, 22% of children suffered from diarrhea, 23% suffered from malaria. That means there is lack of hygienic conditions and this is helping the spread of various poverty associated diseases, while 15% suffered from respiratory diseases and 5% suffered from measles (table 2).

The majority of mothers above 90% (using t-student test) in all areas started to give their children weaning food at 4-6 months except at Alsemeir (78%) and thus showing significant difference from the other three areas [t.sub.167] = 23.2 (p=0.000) as in table (3).

The majority (33%) of the children (table 4) got either starchy food or else starchy food with leafy vegetables (25.5%). This may indicate that poor sources of vitamin A were given to children as weaning food. This also emphasizes the lack of appropriate knowledge on weaning practices and food requirements needed by children f6r healthy development.

Food items donated to respondents from Shambat constituted 80% Mulah and 20% Mulah + bread (table 6). The food items donated to respondents from Alryad were Mulah (55.5%), vegetables + fruits (25%) and Mulah + bread 19.5% (table 7). This means those living in Alryad area had access to sources of VA from vegetables and fruits provided by the surrounding communities.

Only a very low percentage (10%) of the mothers received vitamin A supplements during pregnancy. This might have negatively affected the health of new born infants under 6 months who are normally exclusively breast fed and because the first few breast feeds should particularly be rich in vitamin A (table 9).

In this study the area of residence was found to be of importance in connection with the nutritional status. Shambat was the area where 64% of the children were well-nourished (table 8). Getting food support from surrounding communities was more frequent (90%) in Alryad (table 5). The times that the child received VA depended on the area where the child was born. Ninety percent (90%) of children from Daralsalam were receiving VA supplement (table 10). Suffering from VAD, malnutrition and night blindness depended also on the area from where the sample was selected. The results have also shown that VAD in the study sample was 46% (table 11).

The study put in evidence that residential area is a very important factor in nutritional status; food support from surrounding depend on the area of living (p=0.000). Alryad is the area where the support is more frequent compared with Shambat (table 23), while nutritional status of children is significantly different, ([X.sup.2] = 29.408), in such way that 64% of children in Shambat were well nourished compared with the children in the other three areas, 41% from Daralsalam, 38% from Alsemeir, and 32% from Alryad (table 8).

Inspire of support; Alryad area revealed bad status of nutrition for children compared to Shambat where the support is less and this may be due to many factors such as: the supportive food taken only by the elders, or the supportive food is not regular, although the quality of the supportive food in Alryad contains vegetables and fruits. Receiving VA supplement, as well is significantly different ([X.sup.2] =69.084); in Darasalam 90% compared with the other three areas where 77% were from Alsemeir, 59% from Shambat, and 32% from Alryad (table 10).

However, in conclusion, this study has shown that the prevalence of VAD in different areas was: in Daralsalam 59%, Alsemeir 38%, Alryad 49%and Shambat 32%. The percentage of night blindness was 23 % at Daralsalam, 6% at Alsemeir, and 8% at Shambat and none at Alryad.

Irrespective of the area of residence, communities of low socioeconomic status suffered from VAD. Shambat was the area where the percentage of VAD was lowest, while Daralsalam was the area where VAD was of highest prevalence. The number of times that a child received VA depended on the area where the child-was resident and Daralsalam was the best area to provide children (90%) with VA supplements.

It was also concluded that populations of low socio-economic status living in residential pockets among populations of high socioeconomic status were comparatively better than those who lived in urban slums due to the food support provided by the surrounding communities.

The study put in evidence that the residential area is a very important factor in nutritional status; food support from surrounding depend on the area of living (p=0.000). Alryad is the area where the support is more frequent compared with Shambat (table 5), while nutritional status of children is significantly different, ([X.sup.2]=29.408), in such way that 64% of children in Shambat were well nourished compared with the children in the other three areas, 41% from Daralsalam, 38% from Alsemeir, and 32% from Alryad (table 8).

Inspite of support; Alryad area revealed bad status of nutrition for children comparing with Shambat where the support is less and this may be due to many factors such as: the supportive food taken only by the elders, or the supportive food is not regular, although the quality of the supportive food in Alryad contains vegetables and fruits. Receiving VA supplement, as well is signifcantly different ([X.sup.2] =69.084); in Darasalam 90% compared with the other three areas where 77% were from Alsemeir, 59% from Shambat, and 32% from Alryad (table 10). Finally, the following recommendations were seen pertinent to make:

(1) Nutrition and health education directed to those populations must include:

* Family planning.

* Breast feeding practices.

* Gradual weaning.

* Feeding practices for the sick children and the bad food taboos and habits.

* Nutritive value of locally produced cheap foods rich in vitamin A.

(2) Control of endemic diseases through immunization mad better sanitation conditions.

(3) Promoting nutritional programs that include treatment of vitamin A deficiency and giving prophylaxes every six months.

(4) There should be a full integration between health programs and nutritional programs because there is a high association between infectious diseases and vitamin A status.

(5) Training of health personnel, so that they are capable of early detection of VAD.

(6) Effecting sustainable programs of VA supplementation in risk areas of low socio-economic status.

(7) Raising the socio-economic status through income generating activities.

(8) National wide surveys are necessary to determine the magnitude of prevalence of VAD.
Table 1: Daily income of the family in Sudanese pounds (L.S.)

Income(L.S.) Frequency Percentage Valid %

0-2999 97 61 61
3000-5999 54 33 33
6000-8999 6 4 4
>=9000 3 2 2

Total 160 100 100

Table 2: The distribution of the diseases for the four studied areas

Diseases Frequency Percentage

Diarrhea 64 22
Malaria 78 23
Measles 15 5
Respiratory
 Diseases 45 15
Diarrhea +
 Malaria(D&M) 48 16
Diarrhea +
 Measles(D&M) 3 1
Diarrhea +
 Respiratory
 diseases (D&R) 18 6
Malaria + Measles
 (M & Me) 8 2.7
Malaria +
 Respiratory
 diseases (M & R) 15 5
Measles +
 Respiratory
 diseases (Me & R) 1 0.3

Total 295 100

Table 3: Residence and the child's timing for starting weaning food

Residence <4 months 4-8 months

 Number Percentage Number Percentage
Daralsalam 0 0 94 94
Alsemeir 10 14 54 78
Shambat 2 3 56 97
Alryad 0 0 48 96

Residence More than 9 months

 Number Percentage
Daralsalam 6 6
Alsemeir 5 8
Shambat 0 0
Alryad 2 4

Table 4: Food items given by mothers to their children as weaning food

Food items Frequency Percentage Valid %

Milk (M) & Milk Product (MP) 2 1.5 1.5
Legumes (L) 1 0.5 0.5
Leafy Vegetables (LV) 1 0.5 0.5
Starchy Food (SF) 53 33 33
All of the above 27 17 17
M&MP + L 13 8 8
M&MP + LV 2 1.5 1.5
M&MP + SF 11 7 7
L + LV 2 1.5 1.5
L + SF 7 4 4
LV + SF 41 25.5 25.5
Total 160 100 100

Table 5: Relation between residence and getting food support from
surrounding communities

Residence No Yes

 Number Percentage Number Percentage

Shambat 35 88 5 12
Alryad 4 10 36 90

P = 0.000

Table 6: Food items obtained by responding mothers in Shambat from
surrounding communities

Food items Frequency Percentage Valid %

Mulah * 4 80 80
Vegetables & Fruits 0 0 0
Meat 0 0 0
All of the above 0 0 0
Mulah +bread 1 20 20
Total 5 100 100

* Stew from vegetables and meat

Table 7: Food items obtained by responding mothers in Alryad from
surrounding communities

Food items Frequency Percentage Valid %

Mulah * 20 55.5 55.5
Vegetables & Fruits 9 25 25
Meat 0 0 0
All of the above 0 0 0
Mulah + bread 7 19.5 19.5
Total 36 100 100

* Stew from vegetables and mea

Table 8: Showing the relation between residence and nutritional state
of children

Residence Well nourished Moderately
 malnourished

 Number Percentage Number percentage

Daralsalam 42 41 43 42
Alsemeir 30 38 16 21
Shambat 39 64 13 20
Alryad 17 32 15 28

Residence Severely malnourished

 Number percentage

Daralsalam 12 17
Alsemeir 32 41
Shambat 9 15
Alryad 21 40

[X.sup.2] =29.408

Table 9: Mothers receiving VA supplements during pregnancy

Response Frequency Percentage Valid %

No 105 66 66
Yes 16 10 10
Did not know 39 24 24
Total 160 100 100

Table 10: Children receiving VA supplement by residence

Residence Not received Once

 Number Percentage Number Percentage

Daralsalam 0 0 10 10
Alsemeir 6 8 12 15
Shambat 8 13 17 28
Alryad 25 48 11 20

Residence Twice or more

 Number Percentage

Daralsalam 93 90
Alsemeir 60 77
Shambat 36 59
Alryad 17 32

[X.sup.2] = 69.084

Table 11: Area of residence by suffering from VAD on basis of ocular
abnormalities observed

Residence No Yes

 Number Percentage Number Percentage

Daralsalam 42 41 61 59
Alsemeir 48 62 30 38
Shambat 41 68 20 32
Alryad 27 51 26 49
Total 158 54 137 46

[X.sup.2] = 6.486

Table 12: Residence and night blindness

Residence No Yes

 Number Percentage Number Percentage

Daralsalam 79 77 24 23
Alsemeir 73 94 5 6
Shambat 55 92 6 8
Alryad 53 100 0 0


References

(1.) United Nations (1990): Elimination of Vitamin A Deficiency and Resulting Blindness in Children and Development in 1990s. New York: UN.

(2.) Mohamed, M. and Hassan, S. (1999): Vitamin A Deficiency as a Health Problem Among Children Aged 6 Months to 6 Years: Dissertation submitted to the School of Family Sciences. Ahfad University for Women, Omdurman, Sudan.

(3.) Izzideen, S. and Tanios V. (1996): Hidden Hunger: Vitamin A Deficiency Among the Displaced Children In Khartoum: Dissertation submitted to the School of Family Sciences. Ahfad University for Women, Omdurman, Sudan.

(4.) Kuhhlein, Harriet (1997): Culture, Environment and Food to Prevent Vitamin A Deficiency. Boston: INFDC.

(5.) Under Wood, B. A. (1992): Hypovitaminosis A : Hidden Hunger, News on Health Care in Developing Countries, (special issue), Vol. 6.

(6.) El-Karib, N. (1989): Plasma Retinol and Tocopherols of Breast Feeding Sudanese Women, Tropical Medical Parasitology, Vol. 40, No: 4, p.405-408.

(7.) Hussain M. (1991): Xerophthalmia in Malnourished Sudanese Children, Tropical Doctors, Vol. 21, No. 4, P. 139-141.

(8.) NDN and WHO (1997): A Comprehensive Nutrition Survey: Report-Kassala, Daffur, N. Kordofan, Red Sea, Gezira and Nahr Elneil States, Khartoum: Ministry of Health and Nutrition Departments.

Elham Ahmed Hamed, Ahmed Abdel Magied and Ammar Hassan Khamis (School of Family Sciences, and School of Organizational Management, Ahfad University for Women, Omdurman, Sudan.)
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No portion of this article can be reproduced without the express written permission from the copyright holder.
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Author:Hamed, Elham Ahmed; Magied, Ahmed Abdel; Khamis, Ammar Hassan
Publication:Ahfad Journal
Geographic Code:6SUDA
Date:Dec 1, 2001
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