SUDANESE JOURNAL OF PAEDIATRICS

2023; Vol 23, Issue No. 1

ORIGINAL ARTICLE

Nutritional status and dietary habits among Quranic school’s (Khalwa) students in Khartoum State, Sudan: a cross-sectional study

Ahmed Abdulgadir Noureddin (1), Abubaker Emadeldin A. Koko (1), Mohammed A. Adam (1), Almegdad Sharafaldin M. Ahmed (1), Ahmed Abdallah A. Mahmoud (1), Mohammed Almojtaba Abdalhameed (1), Mohammed Elkhalifa (1), Anoud Omer (2)

(1) Faculty of Medicine, University of Khartoum, Khartoum, Sudan

(2) King Abdulaziz University Hospital, Saudi Arabia

Correspondence to:

Ahmed Abdulgadir Noureddin

Faculty of Medicine, University of Khartoum, Khartoum, Sudan.

Email: gadoura95 [at] gmail.com

Received: 30 January 2021 | Accepted: 23 June 2022

How to cite this article:

Noureddin AA, Koko AEA, Adam MA, Ahmed ASM, Mahmoud AAA, Abdalhameed MA, Elkhalifa M, Omer A. Nutritional status and dietary habits among Quranic school’s (Khalwa) students in Khartoum State, Sudan: a cross-sectional study. Sudan J Paediatr. 2023;23(1):82–87. https://doi.org/10.24911/SJP.106-1611995163

ABSTRACT

Khalawi are non-governmental, traditional educational boarding institutions, widely scattered in Sudan. Many Khalawi are resource-limited with deficient feeding and poor housing conditions, which could seriously affect the students’ health. A cross-sectional study was conducted, involving all students of a Khalwa in Sharg Al-Neel Locality, Khartoum State. Demographic data were collected using a structured questionnaire with anthropometric measurements, along with laboratory and clinical assessments for anaemia. The dietary behaviours of students were also assessed using Global School-based Health Survey. Statistical analysis was conducted using SPSS software. A total of 131 students were included in this study. Their mean age was 13.7 ± 2.7 years, nearly half of them were from Darfur State in western Sudan, and the majority of them are primary school students. Upon assessment, many displayed serious symptoms and signs of anaemia namely: conjunctival pallor, palmar pallor, fatigability, lightheadedness and palpitation. Based on their haemoglobin testing, 95% were anemic and 24% had severe anaemia. Although 63.6% of them had normal body mass index (4.5%), 11.4%, were found ‘severely thin’ and ‘thin’, respectively. Regarding their dietary habits, 46.8% of them consumed milk or milk products less than one time per day, while 20.6% did not consume milk products in the past 30 days. Moreover, 39.4%, 44.9% and 39.4% did not consume any vegetables, fruits or fruit juice, respectively, in the past month. Students of Khalwa displayed poor dietary habits, which resulted in nutritional deficiencies. Programmes must be directed towards improving the quality of diet provided at these schools.

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KEYWORDS:

Nutrition; Khalwa; School health; Anaemia.

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INTRODUCTION

The Khalwa (Khalawi for Plural) is a non-governmental boarding school, widely spread in Sudan [1]. It is considered the oldest educational institutions in Sudan, with its main goal of education to learn and recite the Quran. Students come from various areas of Sudan, and even neighboring countries to stay and study in these Khalawi, with their staying period ranging between 6 and 8 years. Most Khalawi attendees are males, and the students have to study on a daily basis from early morning until noon, then they pause for eating and some rest before resuming their studies several hours later in the afternoon [2]. The diet provided to the children at the Khalwa is mostly nutritionally deficient [3].

Malnutrition is a major health concern for the developing countries, and it is generally connected with poverty [4]. School students’ nutritional status is considered crucial for children’s educational development, as several studies demonstrated that malnutrition is linked with negative implications on intelligence, high levels of early drop-outs, delayed development and deficient classroom performance [5–7]. Additionally, nutritional deficiencies possess a great risk to children’s health, and can endanger their growth, productivity and even life [8]. Anaemia is one of the major and most common nutritional deficiencies, as it is estimated to affect nearly a quarter of school children worldwide [9]. Anaemia was found to be associated with major negative health and educational consequences [10,11]. Previous studies reported many nutritional deficiencies including anaemia among Khalawi’s students [1–3], yet with less focus on their dietary habits. The present study aims to assess both the dietary habits, nutritional status, of Khalwa students, with a focus on the prevalence of anaemia.

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MATERIALS AND METHODS

This study was a cross-sectional school-based study, conducted at Mustafa Alfadni Quran Recitation Boarding School for boys (i.e. Khalwa), in a suburb of Sharg Al-Neel Locality, Khartoum State, in early October 2017. This Khalwa was chosen since it receives students from all over Sudan, and is considered one of the major Khalawi in Khartoum. A total coverage for all students in the Khalwa was done, and every student found in the Khalwa during the period of study was included, with the exclusion of those who did not agree to participate.

The data were collected by a pre-tested and validated questionnaire, which consisted of five parts. The first part focused on the socio-demographic characteristics of the students and their parents, including students’ age, original hometown, level of education and their length of stay in the Khalwa, as well as their parents’ level of education. The second part of the questionnaire was to record anthropometric measurements, namely weight and height, using a portable weighing scale and a locally made stadiometer with a sliding headpiece. The body mass index (BMI) was calculated and plotted to WHO centile charts of BMI for age [12]. Accordingly, students were classified into the following categories: severely thin, thin, normal, overweight and obese.

The third part was used for assessing clinical symptoms and signs of anaemia (i.e. fatigability, palpitations, lightheadedness, conjunctival pallor, palmar pallor, angular stomatitis, atrophic glossitis, Koilonychia, and pica), in which history and examination were done by a pediatrician.

The fourth part was used to record haemoglobin levels, and blood samples were collected. A portable colorimeter using 15 g/dl haemoglobin standard as a reagent was used to measure the level of haemoglobin in blood according to the guidelines. These processes were done by a senior laboratory technician.

Finally, the fifth part aimed to assess the students’ dietary habits, using part of the Global school-based health survey.

Data collected were coded, cross-checked, and entered on a daily basis. Descriptive and comparative analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 23.0 (SPSS Inc., Chicago, IL). Categorical variables were expressed in frequencies and percentages, whereas continuous variables were in means and SDs.

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RESULTS

The study included 131 male participants, with a mean age of 13.7 ± 2.7 ranging from 6 to 24 years, with nearly half originating from Darfur in western Sudan (47.7%). The majority received primary schooling (70.2%), yet about half of their fathers (47.4%), and even more mothers (55.8%) did not receive any formal education.

Regarding BMI measurements, according to WHO classification, 11.4% of the total students were found to be ‘Thin’ for their age, and another (4.5%) were ‘Severely thin’.

A sizeable percentage of respondents reported symptoms and signs of anaemia as follows: conjunctival pallor (56.1%), palmar pallor (35.8%), fatigability (18.8%), lightheadedness (13.8%), and palpitation (10.3%); with other signs (angular stomatitis 2.1%, atrophic glossitis 4.3%, pica 4.3%, and Koilonychia 6.3% being less evident. Clinically 40%, 23.3% and 3.3% were diagnosed with mild, moderate and severe anaemia, respectively, yet according to their estimated haemoglobin level using laboratory investigation and WHO classifications; (11%), (59.3%) and (24.2%) were classified as mild, moderate and severe anaemia, respectively.

Regarding dietary practices during the 30 days prior to the study, 79.5% had breakfast meals regularly. For those who skipped breakfast, ‘unavailability of food’ was the most common reason (11%). In addition, 14.2% stated that breakfast is only offered sometimes. Nearly half of the students (46.8%) consumed milk or milk products less than one time per day, while 20.6% did not have milk or its products at all. Consumptions of vegetables, fruits and fruit juice were generally low, since 39.4%, 44.9% and 39.4% reported no consumption of vegetables, fruits and fruit juice, respectively, during the last month. A majority of students (63% and 54.3%) consumed high fats food, and carbonated soft drinks less than one time per day, respectively (Table 1).

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DISCUSSION

This study highlighted the important role of dietary practices on the nutritional status of students attending the Quranic schools (Khalawi), and the implications of poor dietary habits and feeding arrangements in these Khalawi on their health; especially the development of anaemia, since anaemia and nutritional deficiencies are very common health issues repeatedly reported among Khalawi students in general [1–3].

Length of stay in the Khalwa was not found to be correlated with the development of anaemia and nutritional adversities (p =0.59). This contradicts the study conducted by Kheir et al. [3] among Khalwa students. This difference may be explained by the adverse socioeconomic backgrounds from which these students come. These socioeconomic backgrounds might expose the students to different quantities and quality of feeding while growing up.

In this study, 67% of the children were clinically diagnosed with mild to severe anaemia, and more than half of them were having conjunctival pallor. This result is comparable with a similar study conducted by Eltayeb et al. [2] in Gezira State, Central Sudan, in which pallor was only reported among 43% of the participants. Furthermore, in that study, anaemia was confirmed by haemoglobin testing and documented among 88% of the total children; however, in the present study, it was detected in 95%. Compared with neighboring countries, the prevalence of anaemia in this study was higher than all of them. Anaemia among school children was reported only in 16%, 29% and 59%, in Ethiopia, Kenya and Egypt, respectively [13–15]. Similarly, anaemia prevalence in this Khalwa was more than other African countries, including Cape Verde and Nigeria, in which the prevalence was 24% and 29%, correspondingly [16,17]. This huge difference might be due to many factors including dietary habits and nutritional constituents of children’s meals.

Several studies have reported that parental education was significantly associated with anaemia among school children. Parents with more formal education tend to have fewer anemic children [13,18,19]. However, in this study the association was insignificant (p=0.4) for mothers’ level of education. This might be due to the fact that these children rarely leave the school during their educational period and hence their parental level of education has less effect on their health.

Table 1. Dietary practices of Khalwa students during the 30 days prior to the study.

		Count	Percentage (%)
During the last 30 days, how often did you have a breakfast?	Never	0	0.0
	Rarely	1	0.8
	Sometimes	10	7.9
	Most of the time	15	11.8
	Always	101	79.5
What is the main reason you do not have a breakfast?	I always eat breakfast	101	79.5
	I don’t have time for breakfast	3	2.4
	I can’t eat early in the morning	6	4.7
	There is not always food in my home	14	11.0
	Some other reason	3	2.4
During the past 30 days, how many times per day did you usually drink milk or eat milk products such as fermented milk ‘Roob’?	I did not	26	20.6
	Less than one time per day	59	46.8
	One time per day	17	13.5
	Two times per day	12	9.5
	Three times per day	9	7.1
	Four times per day	2	1.6
	Five or more times per day	1	0.8
Drinking fruit juice in the last 30 days (per day).	I did not	50	39.4
	Less than one time per day	46	36.2
	One time per day	9	7.1
	Two times per day	19	15.0
	Three times per day	2	1.6
	Four times per day	0	0.0
	Five or more times per day	1	0.8
Eating fruit per day in the last 30 days	Did not eat fruit	57	44.9
	Less than one time per day	54	42.5
	One time per day	11	8.7
	Two times per day	4	3.1
	Three times per day	1	0.8
	Four times per day	0	0.0
	Five or more times per day	0	0.0

The dietary intake of the respondents in the 30 days prior to conduction of the survey showed that 79.5% had breakfast meals regularly and 20.5% skipped it. This agrees with Akinyemi [20] study, in which he reported that the nutrients intake of the boarding students was generally low. Additionally, this study revealed that consumption of vegetables, fruits and fruit juice was low, since 39.4%, 44.9% and 39.4% of the participants did not consume any of the above nutrients, respectively. Similarly, Peltzer and Pengpid [21] stated that 77.5% of the children consumed less fruits/vegetables than the recommended daily intake. Furthermore, 20.6% of the Khalwa students did not consume milk products. This finding is congruent with the results of Bolajoko et al. [22] among school children, which stated that vitamins E, B6, Folic acid and vitamin C were found to be lower than the recommended dietary allowance and mineral intake. Their study also showed that there was low consumption of calcium intake (43%) among boarding students, and the same goes for folic acid, since its intake was also low with a percentage of 47%. This might explain the significantly high percentages of anaemia in this Khalwa, since the deficiency in these nutrients might be the leading cause of anaemia.

The BMI of the children showed that about two-thirds of them (65.1%) were within the normal range and the rest were divided between overweight and underweight. The mean was 18.5 kg/m² which was near to the mean BMI found in a study done on two boarding secondary schools of females in Ondo, Nigeria, in which it was found to be 18.8 [23]. It was less than the BMI of college students in a study done in Lagos, Nigeria which was 21.3 [20].

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CONCLUSION AND RECOMMENDATION

Khalwa students displayed poor dietary habits and feeding patterns which resulted in deficient nutritional status and high prevalence of anaemia. Programs need to be directed toward improving the quality of diet offered at these Khalawi, with an involvement of all stakeholders; policymakers, community leaders and organisations. In addition, educational programs need to be designed to raise the awareness about healthy dietary habits among students, parents and teachers.

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ACKNOWLEDGMENT

The authors are thankful for all Khalawi health promotion team, and all doctors and technicians who made this work possible.

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CONFLICT OF INTEREST

The authors declare that they have no competing interests.

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FUNDING

This study was part of Phase 1 (screening phase) of Khalawi Health Promotion Project, performed by Khartoum Medical Students Association (KMSA) Health Education Secretariat. Phase 1 of the project was funded by the United Nations International Children’s Emergency Fund (UNICEF), Sudan Headquarters in Khartoum State.

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ETHICAL APPROVAL

Ethical approval was obtained from the Institutional Review Board at the Ministry of Health, Khartoum State, Sudan, as well as a written approval from the Federal Ministry of Religious Endowments, and the approval of Mustafa Alfadni Khalwa Administration. Prior to data collection, the study objectives were explained to participants, and informed consent was obtained from each participant.

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