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Malnutrition: The Forgotten Epidemic in Indonesia and India

A Joint Article by the Journalism Team of SBE UISC 2021 and SBE VIT 2021


This article was made to support SBEWARE, an annual event organized by SBE UISC that aims to raise awareness regarding social issues. This year, SBEWARE is bringing the theme of health education in collaboration with Save The Children Indonesia to help stunted children. We are still open for donations that will be allocated to distribute supplements, nutritious food and educate pregnant moms and healthcare workers on the importance of nutrition. You are more than welcomed to contribute through the link below:

https://kitabisa.com/campaign/GiatGiziUntukNegeri

As developing countries, Indonesia and India still have a long way to go to tackle malnutrition problems, such as stunting. Stunting is an indicator of chronic undernutrition, the result of prolonged food deprivation and/or disease or illness. Commonly found in children under five, stunting is signed by height that is less than -2 standard deviations from the WHO child growth standards median. Survei Status Gizi Balita Indonesia (Indonesian Under-fives Nutritional Status Survey, SSGBI) showed that the prevalence of stunting in 2019 was 27.67%, decreasing by 3.13% from the previous year. Although progresses have been made, the prevalence still exceeded 20%, the limit set by WHO. In 2002, UNICEF estimated that the prevalence of stunting among children less than 5 years old in India was 45%. The stunting rate in both countries varies among different regions.


Stunting Prevalence in Indonesia and India

In Indonesia, 27% of children under five in Kepulauan Riau Province were stunted as of 2013, while in Nusa Tenggara Timur Province the number is more than 50%. Until recently, Nusa Tenggara Timur is still known to have 21 cities or districts that had a high or very high stunting prevalence. It is regarded as one of the Indonesian provinces with high-prevalence cities, along with East Java (23 cities), South Sulawesi (20 cities), and North Sumatera (20 cities).

Table 1. Number of Cities/Districts in Indonesia by Severity Level of Stunting (2018)

Severity of Stunting

​Number of Districts/Cities

Low

35

Medium

181

High

206

Very High

92

India’s high-stunting districts are heavily clustered in the north and centre of India. Differences in stunting prevalence between low and high burden districts were explained by differences in women's low body mass index (19% of the difference), education (12%), children's adequate diet (9%), assets (7%), open defecation (7%), age at marriage (7%), antenatal care (6%), and household size (5%).


Table 2. Number of Districts, Stunting Rate, and Absolute Numbers of Stunted Children in India by Prevalence of Stunting (2018-2019)

​Prevalence of Stunting

Number of Districts

​Stunting rate (%)

Stunted Children

Low (<20%)

26

16.9

723.651

​Medium (20-29.9%)

170

25.9

8.872.991

High (30-39.9%)

202

35.2

16.363.830

​Very high (≥40%)

239

46.9

37.179.537

Factors of Stunting

The UNICEF framework distinguishes between immediate determinants (diets and disease burdens) and underlying determinants. The immediate determinants included indicators related to maternal undernutrition and child feeding practices. A BMI < 18.5 kg is regarded as grounds for maternal undernutrition. The underlying determinants examined included the mother's education (≥10 years of schooling), age at marriage (≥18 years old), sanitation, asset index, and household size.


Maternal malnutrition is considered as the main factor of stunting, both in Indonesia and India. This is shown by the prevalence of stunting in Indonesian newborn babies that reached 23%. In India, about 36% of the population of women are underweight, and 56% of women and 56% of adolescent girls between 15 and 19 years old suffer from iron deficiency anemia due to undernourishment. It is confirmed that the probability of stunting caused by deficiencies in the intrauterine environment is equivalent to stunting caused by the child’s health and nutrition during their early postnatal life. Nutrition requirements in pregnant and lactating women are higher since their energy needs increase by 13% during pregnancy and 25% higher during lactation. However, this necessity might not be supported by adequate women’s education, sanitation systems, and food security.


The current pandemic situation has led to a dependency on imports of rice and soybean, two staple foods in Indonesia. These conditions are fathomed as the results of hydro-meteorological disasters such as floods and land fires that keep occurring. The risk of such disasters is influenced especially by the accelerating climate change. The rising temperature, humidity, and rainfall can lead to changes in plant physiology, plant diseases, and lower productivity. For example, the El Nino phenomenon in Maluku induced a decline in soybean yield by 10.7%, while La Nina dropped it by 11.4%. In the context of animal protein, Indonesia is also threatened by climate change as well as destructive fishing, illegal fishing, and land-based pollution. Besides that, the rapid growth of population and urbanization has prompted agricultural land conversion.


While in India, it is the poor sanitation system and low women’s education level that plays a more pivotal role in causing chronic malnutrition and stunting in children. Poor sanitation systems include open defecation and access to unsanitary drinking water. It is approximated that 620 million Indian people use public toilets to defecate outside, especially in rural households. Infection through drinking water can result in the reduction of nutrients absorption. Besides that, poor sanitation leads to the possibility of water pooling, which due to the influx of garbage and refuse, becomes the perfect environment for mosquitoes to breed and transmit malaria. Regarding women's education level, a study has shown that Indian districts with higher rates of female literacy have less stunting prevalence on average. This result aligns with another finding that shows children of lower-ranking mothers tend to have shorter heights.


Similar Diseases

Other diseases resulting from malnutrition and protein deficiency include marasmus (caused by inadequacy of nutrients) and kwashiorkor (seen in famine-struck regions) which are still prevalent in both countries. The general yet major determinants of these diseases are broadly classified into environmental factors including the physical and social environment, behavioral factors, healthcare service-related, and biological factors (genetic/prenatal).

Sanitation and food supply monitoring in Indonesia (source: https://www.who.int.com/)


Areas that have famines or poor environmental sanitation have higher percentages of children with marasmus. In Indonesia, other than hygiene problems in some areas, many families don’t have enough income and thus are unable to buy nutritious food for their children. A cross-sectional study was conducted in a single tertiary referral hospital in Bali, Indonesia, from January 2017 to December 2018. From a total of 138 children with acute malnutrition, 133 children (96.4%) were classified as marasmus and 15 children (10.9%) were suffering kwashiorkor. Marasmus is often found in children who do not get enough breast milk and only get formula or toddlers who are given weaned food too early or too late, while kwashiorkor is often found in rural areas where people consume more staple food in the form of carbohydrates than great quality protein.

Record data of types of malnutrition prevalences a single tertiary referral hospital in Bali (source: https://www.media.neliti.com/)


India stands at a very vulnerable position with one of the highest prevalences of undernutrition in the world in spite of improvement in food availability and poverty alleviation. It is the direct cause of about 300,000 deaths per year and is indirectly responsible for about half of all deaths in young children. A study conducted in Maharashtra shows a maximum of 63% of marasmic kwashiorkor and malnourished children between the ages of 2-3 years. Cases of Marasmus alone was 13% and kwashiorkor was recorded to be 24% at the site of study. In rural regions of India, the prevalence of marasmus is dominated over kwashiorkor due to various factors that are specific to the country.

Normal curve distribution of children in the underweight category (source: NFHS data)


Crucially, protein-energy malnutrition has two kinds of impacts on growth - cognitive growth (including behavioral changes) and physical growth. To function optimally, the central nervous system requires a variety of amino acids, some of which are crucially supplemented by diet. Without the necessary supplementation of protein, adverse impacts on the brain occur. These look like tissue damage, disorderly differentiation, reduction in synapses and synaptic neurotransmitters, hence resulting in delayed reception by younger children. The second impact is the loss of adipose tissue and muscle. Infants may have sunken fontanelles due to dehydration. The affected child will weigh less than 60% of the appropriate weight for their age.


Superfoods as Solution for Undernutrition

One way to deal with stunting that is constantly being researched and developed is the usage of superfoods. Superfood is the term coined for food that has beneficial, health-promoting properties due to its nutrient-rich nature. In Indonesia, the most well-known superfood is Moringa oleifera or daun kelor, with its leaves as the main part to utilize. A research in Indonesia conducted in 2018 also showed that Moringa oleifera extract can increase toddlers’ height. The results showed that Moringa oleifera extract could increase body height by 0.342 cm with a prediction of 16.2%.


Moringa leaves are highly rich in protein, calcium, potassium, fiber, and vitamins. 100 gr of moringa leaves contain 6.7 grams of protein and 0.9 grams of fiber. Moreover, since Moringa is a legume, it enriches the soil and is drought-resistant. It propagates easily, offering a way for malnourished populations to get themselves healthy again without a constant influx of food provisions from outside sources. This leads to the possibility of making supplementary foods based on moringa leaves to deal with stunting on children.


A realization of said possibility is the production of chicken nuggets with Moringa leaves in Probolinggo, East Java. Upon further analysis, the nutrient levels of chicken nuggets with 50 g of moringa leaves contained 18.4% crude protein, 2.8% crude fat, and 3.4% crude fiber. While the amount of crude protein and fat are not far off from chicken nuggets without moringa leaves, the amount of crude fibre is definitely higher.


Moringa has also long been used in India as a medicinal plant and thus a nutrient booster. Aside from that, superfoods such as spirulina capsules and candies are gaining popularity for overcoming stunting. Spirulina chikki is a seaweed nutritional superfood that is made by stuffing spirulina with traditional peanut jaggery chikki. It has gained popularity all over India for its high nutritional content which can successfully combat the problem of stunting and malnutrition, as it is easily available to malnourished children belonging to different sections of society. According to studies conducted, a single tablespoon (7 grams) of dried spirulina powder contains proteins, vitamins B1, B2, & B3, minerals such as copper and iron, and minimal amounts of almost every other nutrient that one needs.

Superfoods to combat malnutrition: Moringa leaves (left) and spirulina chikki (right) (source: https://www.indiatoday.in)


Holding on to all the facts stated, both Indonesia and India are still facing similar issues regarding nutrition. The inequality of nutritional conditions between cities is present in both countries. The profile of malnutrition in the two countries shows that socioeconomic and environmental circumstances are the prominent cause of this burden. Among malnutrition diseases, stunting is one of the most prevalent. These conditions are affected by maternal malnutrition, food insecurity, and poor sanitation. To help alleviate malnutrition problems, several kinds of superfoods are being developed, such as moringa chicken nuggets and spirulina capsules. However, aside from that, there should be concrete actions taken by the government to tackle malnutrition problems.



 

References

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