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Lessons learnt from TTS: Different Approaches in dealing

with stunting preventions

Elviyanti Martini

WFP Supports GoI
in 3 areas

Country Programme Action Plan
2012-2015
1) Monitoring, analysis, mapping and
response to food and nutrition insecurity;

2) Emergency preparedness and response
and building resilience among vulnerable
population groups;

3) Reducing under-nutrition below critical
levels (Nutrition, HIV, School Meals and FFA).

Reducing undernutrition is a key priority for both WFP
and the GoI
Stagnating/Increasing stunting
36.8% (2007) to 37.2% (2013)=9 million children
Great disparities at subnational level with highest
prevalence in NTT (51.7%) and NTB (45.3%)

Resilient wasting
13.9% U5 (2013) = 3.3 million children

Emerging overweight
11.9% U5, 32.9% of women, 19,7% of men

Deteriorating maternal health
24.2% of pregnant women have CED and 37.1% anemia
One of the highest maternal mortality rates in Southeast
Asia: 359 per 100,000 births

WFP supports GoI through two-tiered
strategy
WFP Nutrition Strategy
Support GoI in its efforts to fight child and maternal
undernutrition
especially by increasing access to the right food at the right time
during the first 1,000 days

I) Policy advocacy and
capacity development

II) Prototypes of
nutrition-specific and
nutrition-sensitive
interventions

Focus on supporting policies and enabling their
implementation through appropriate tools

I) Policy advocacy and capacity development

Knowledge
building and
transfer

Tools for evidencebased decisions
and policies

Support to policy
design and
implementation

Technical workshops

Cost of Diet

Participation to
exchange forums such
as nutrition think
tanks, MIYCN Working
Group, GKIA

Food Security and
Vulnerability Atlases

Scaling Up Nutrition
(SUN)

Food Security Monitoring
System

Food and Nutrition
Surveillance System

Food and Nutrition
Action Plan
(National, Provincial and
District levels)
Nutrition sector
review, RPJMN 20152019
National standards for
supplementary and
complementary feeding

EXAMPLE: the Cost of the Diet tool (CoD)
Linking economic access to poor nutritional outcomes:
Findings of the CoD In several districts, affordability of
nutritious diet is problematic

Baldi G. et al.,Cost of the Diet (CoD) tool: First results from Indonesia and applications for policy discussion on food and nutrition
security. (2013).

100
90
80 [CELLRA
70 NGE]
60
50
40
30
20
10
0

20

30

[CELLRA
NGE]
[CELLRA
NGE]

[CELLRA
NGE]
40

50

Prevalence of stunting

60

Percent of households that can
afford LACON diet

Percent of households that can
afford LACON diet

Hubungan antara kemampuan membeli
makanan bergizi dan kekurangan gizi
100
90
80
70
60
50
40
30
20
10
0

[CELLRA
NGE]
[CELLRA
NGE] [CELLRA
NGE]

[CELLRA
NGE]
10

20

30

40

Prevalence of underweight

50

Commitment to
stunting

Prevalence of stunting in
children aged less than
five years by wealth
quintile in 2007, 2010 and
2013 (RISKESDAS) shows
that stunting rates have
increased or stagnated
even in the richest income
quintiles

Since the richer income
quintiles do hypothetically
have the purchasing power
to procure adequate
nutritious products for the
“first 1,000 days” the
market should be able to
offer a solution

As stunting is not just a problem
of the poor, the market can be a
key part of the solution

WFP response focuses on areas with the most pressing
food security and nutrition needs

DRAFT

SO NTB
FFA 17000

SO NTT
School Meal 9480
MCN 15000
FFA 21000

SO PAPUA
School Meal 1750

Nutrition prototypes focus on areas with high
malnutrition prevalence: Nusa Tenggara Timur

Prevalence of
food insecurity

TTS has been a priority 1 area
since 2005 according to FSVA

2005: Indonesia

2010: NTT

2009: Indonesia

2010: TTS

Source: WFP, FSVA from respective years

Trend
kekurangan gizi

Stunting di TTS lebih tinngi dari
rata-rata Indonesia dan NTT

Prevalence of stunting

Prevalence of wasting
25

90
80.65

20

70.43
70
60
50
40

57

58.44
51.73

46.8
36.8

36.6

37.2

30
20

Percentage of population of U5

Percentage of population of U5

80
20

15.44

15.3

15

13.3

14

13.7
12.1

10

11.37

5

10
0

2007

2010

U5: Children under five years of age
Source: Riskesdas from respective years

2013

0
2007

2010

2013

WFP’s prototypes to support GOI to respond both immediate
and underlying causes of undernutrition

Intervensi

WFP fokus pada “window of
opportunity” dalam 1,000 HPK

 Children who are undernourished in the first 2 years of life and who put on
weight rapidly later in childhood and in adolescence are at high risk of chronic
diseases related to nutrition
 Interventions after two years of age are too late as much of the early damage
is irreversible and intervention would be more expensive
 WFP has set a standard for minimum nutritional intake during these
periods, distributes adequate supplements and constantly monitors the
impact

The prototypes focus on the first 1,000 days but also
address nutrition throughout the life-cycle

First 1,000 days

 Improvement of existing
supplementary food products w/
local private sector

 Local development of LNS
 Provision of MP-ASI and LNS
through pilot in TTS
 Evidence-building:
effectiveness, evaluations, Lesso
n Learnt on various delivery
mechanisms
 Support local health sector on
growth monitoring and BCC for
health and nutrition
 Voucher pilot to increase access
to specialized food during 1,000
days

Life-cycle

 Integrated local school meals w/
MNP and BCC
 Support to local farmers
 Food for Assets to improve
resilience

Pemberian ASI dan MP-ASI yang Baik Sangat Penting untuk
Pencegahan Stunting. Vitamin dan Mineral harus mencukupi
Contoh:
Zat besi dan Yodium untuk
perkembangan
kognitif/kecerdasan
Zinc: untuk pertumbuhan
dan fungsi kekebalan
tubuh
Vitamin A: untuk
perkembangan retina dan
system kekebalan tubuh
dan kelangsungan hidup
Photo from UNICEF Azerbaijan

Kapan “Jendela Emas” untuk
memperbaiki PMBA?

Victora C.G. et al, 2010

10 prinsip pedoman pemberian
MPASI untuk anak yang diberi ASI
1. Exclusive breastfeeding (EBF) selama 6 bulan
pertama kehidupan dan pengenalan MPASI pada
usia 6 bulan
2. Tetap memberikan ASI sampai anak berusia dua
tahun atau lebih
3. Pemberian makan yang responsif
4. Penyiapan dan penyimpanan MPASI yang aman
5. Jumlah MPASI yang cukup

18

10 prinsip pedoman pemberian
MPASI untuk anak yang diberi ASI
6. Konsistensi makanan yang tepat
7. Jumlah frekwensi makan yang cukup dan kaya akan energi

8. Mengandung zat gizi yang cukup (zat gizi makro dan gizi mikro)
9. Penggunaan supplemen vitamin dan mineral seperti Taburia dan
MPASI yang berfortifikasi untuk bayi dan ibu
10. Meningkatkan pemberian makanan ketika anak sakit atau
sesudah sembuh dari sakit (e.g. diarrhea)

19

Berapa energy yang dibutuhkan dari
MPASI?
6-8 months

From
Breastmilk
From CF

9-11 months

12-23 months

0

200

400

600

800

1000

kcal
Ukuran lambung bayi terbatas, pada usia 6 bulan ~100mL dan pada usia 24 bulan ~200mL

Kandungan Zat Gizi yang Cukup
Setelah 6 bln, ASI memberikan <50% kebutuhan
untuk beberapa zat gizi
Nutrient
Iron
Vitamin D
Zinc
Vitamin B6
Niacin
Thiamine
Calcium

% of requirement for 6-8 month olds that
must be met by complementary foods
98%
93%
80%
79%
75%
53%
53%

Apa yang bisa kita lakukan…
• Untuk meningkatkan kepadatan energi?
– Kurangi air, buat bubur lebih kental
– Tambahkan minyak pada bubur

• Untuk meningkatkan kepadatan kandungan
gizi (baik gizi makro dan mikro)?
– Diversifikasi – berikan makanan yang bervariasi
– Makanan padat gizi – makanan sumber hewani

Let’s try …
MPASI “Ideal” :
20g nasi
15g kacang-kacangan
15g sayuran hijau
22g (setengah) telur ayam
20g ikan
10g minyak

Persentasi kebutuhan zat besi dan zinc yang
dipenuhi oleh MPASI yang tidak berfortifikasi untuk
anak usia 6-8 bulan
Persentasi kebutuhan
yg dipenuhi dari MPASI
MPASI“Realistik”
20g nasi
15g kacang-kacangan
15g sayuran hijau
22g (setengah) telur
ayam
20g ikan
10g minyak

Sumber: Vitta, Dewey, 2012

Zat Besi yang Bioavailable (zat besi
yang diserap) dari MPASI dalam porsi
100gr
Iron for fied
Green leafy
Absorbed
Iron

Legumes, nuts
Fish

Total Iron

Barley
Egg (chicken)
Chicken
Pork
Beef
0

1

2

3
mg

4

5

Current situation of practices:
Introduction of Complementary Foods and
Minimum Acceptable Diet

Source: DHS of listed countries, 2002-2008

Defisit Zat gizi anak-anak di
amanuban barat dan Kie,TTS
6-11 bulan

12-23 bulan

Energi

6-21%

22-38%

Protein

13-29%

15-34%

Zat Besi

67-81%

60-66%

Sumber: ACHEAF, 2012

Intervensi
program gizi ibu
dan anak
2012-ongoing
Mother and Child Nutrition Programme (MCN)
• Target: 11.500 children 6-24months, 6500 PLW
• Product: MP-ASI and LNS, fortified biscuits,
• Method: 440 posyandu
Local Food Based School Meals (LFBSM)
• Target: 13,000 children 7-12years
• Product: Maize, mung beans, Vitas
• Method: Cooking in 74 schools

2005-2011





2012

2013

Recipients are spread across 440 posyandu
Children receive MP-ASI (3 sachets per day = 1.8 kg/month/child)
30 posyandu have been selected for monitoring and evaluation of anthropometric
data (weight, height and age of children, MUAC of PLW)
Training has been provided to the posyandu to conduct the measurements
Poltekkes University oversees the measurements
Behavior Change Communication is also implemented in all 400 posyandu

2014

WFP Target
areas

Activity area and measurement
is spread across TTS
• MP-ASI Interventions in
17 out of 32
subdistricts
• 440 Posyandu out of
712 are reached by the
Mother and Child
Nutrition Programme
(MCHN)

• 30 Posyandu with
tracking of
anthropometric data
since Q4
2012, selected to
represent the entire
activity area (PPS)

WFP MCHN area
Posyandu participating in anthropometric measurement
Source: WFP

Prevalensi stunting
(Pendek)
Prevalensi stunting
pada baduta berkisar
54.5%

Prevalence of stunting
100.0
90.0
80.0

70.43%
2013 TTS
average
for U5

Percentage of stunting in U2

70.0
59.3

59.3
60.0

50.4

49.8

50.0

44.2
29.7

40.0

56.5

54.5

51.8

26.9

32.0

28.6

27.5

24.5

30.3

23.4

30.0
20.0
10.0

25.0

29.6

22.3

27.3

25.9

20.8

25.9

26.2

0.0

Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 Q1 '14 Q2 '14 Q3 '14
Severe stunting
Moderate stunting
U2/U5: Children under two/five years of age
Source: Riskesdas from respective years; WFP anthropometric measurements

53%
Median of
measurements

Prevalensi
wasting (kurus)
Prevalence of wasting
14.0

14.0%
2013 TTS
average
for U5

12.5
12.0
10.7

 Prevalensi
wasting (kurus)
sudah menurun

Percentage of wasting in U2

10.0
8.7

8.5
7.7

8.0

7.6

7.9

8.6

7.9

7.0
6.0

5.3

4.8
5.7

5.8
5.9

6.2

4.0

2.0

3.7

3.2

3.0
1.9

1.7

3.9
2

2.9

0.0
Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 Q1 '14 Q2 '14 Q3 '14
Severe wasting
Moderate wasting
U2/U5: Children under two/five years of age
Source: Riskesdas from respective years; WFP anthropometric measurements

 Prevalensi
meningkat pada
masa paceklik

Intervensi
lainnya
• Pengembangan home gardening, Embung dan irigasi
melalui program Food for Asset

• FNAP at national, provincial and district levels;
NTT, NTB, Papua

Kesimpulan
1

• Prevalensi of stunting dan wasting lebih rendah pada
daerah dimana ada programme WFP dibanding data TTS
secara keseluruhan dari Riskesdas 2013,

2

• Program perlu dilakukan selama satu siklus penuh selama 3
tahun untuk dapat melihat dampaknya pada
stunting, Penurunan prevalensi wasting menunjukan dampak
positive

3

4

• MPASI berfortifikasi bermanfaat untuk menutup defisit zat
gizi, disertai usaha perbaikan PMBA yang optimal dan perbaikan
lingkungan dan peningkatan pelayanan kesehatan. Apabila tidak
ada defisit energi, pemberian makanan lokal dengan
penambahan taburia dapat dianjurkan
• Program Gizi spesifik dan gizi sensitive harus dilakukan
bersamaan

Thank you