Animal Protein On Stunting Prevention A Narrative

IOP Conference Series: Earth and Environmental Science
PAPER • OPEN ACCESS You may also like

- Factors associated with undernutrition and
Animal protein on stunting prevention: A narrative improvement in Indonesia
A V R Mauludyani, E A Suryana and M
review Ariani
- Modeling of toddler stunting in the

province of east nusa tenggara using
To cite this article: K E Damayanti et al 2024 IOP Conf. Ser.: Earth Environ. Sci. 1292 012027 multivariate adaptive regression splines
(mars) method
D M Azizah and E O Permatasari
- Projecting the impact of air pollution on

child stunting in India—synergies and
View the article online for updates and enhancements. trade-offs between climate change
mitigation, ambient air quality control, and
clean cooking access
Asya Dimitrova, Guillaume Marois, Gregor
Kiesewetter et al.
This content was downloaded from IP address 80.246.30.65 on 19/01/2024 at 12:44

2nd International Conference on Animal Research for Eco-Friendly Livestock Industry IOP Publishing
IOP Conf. Series: Earth and Environmental Science 1292 (2024) 012027 doi:10.1088/1755-1315/1292/1/012027
Animal protein on stunting prevention: A narrative review
K E Damayanti1,2*, Y L R Dewi2, B Wiboworini2 and V Widyaningsih3

1
Doctoral Program of Public Health, Faculty of Medicine Universitas Sebelas Maret,
Surakarta, 57126, Indonesia
2
Department of Nutrition, Faculty of Medicine Universitas Sebelas Maret, Surakarta,
57126, Indonesia
3
Department of Public Health, Faculty of Medicine Universitas Sebelas Maret,
Surakarta, 57126, Indonesia
*Corresponding author’s e-mail: kusmadewi@staff.uns.ac.id
Abstract. Stunting has been a global problem even though adult and child obesity has not been
resolved yet. Various approaches have been carried out in the nutrition field and others. The
Government of Indonesia recently established an effort on stunting reduction acceleration
through its Ministry of Health. The accessibility to healthy food, including sources of animal
protein, become one of its strategies. This study aims to explore the efforts evolved in stunting
reduction, especially regarding access, availability, and provision of animal-based products to
supply the source of animal protein. The review was done narratively from scientific sources
such as Pubmed and Scopus. The 193 articles were derived from the search applying keywords
"protein", "policy", "malnutrition", and "stunting", and their combination using the Boolean
operator. There are 193 studies screened resulting in 159 studies excluded from 3 stages, and 40
studies in the review. The articles were then reviewed systematically using Covidence, a web-
based systematic literature review tool. The study results show that the availability of animal
products is much better, but not yet supported by good distribution and an increase in
accessibility. The government has supported this with sufficient policy, however, more thorough
action is still needed. Thus, sustainable animal farming is needed as one of the strategies to
provide a sufficient quantity of animal products of optimal quality to prevent malnutrition,
especially stunting.
1. Introduction
Stunting has been a health problem that leads to various consequences in the future, not only for the
children suffering from it but also for the community and the nation from a wider perspective. Stunting
has become a global burden. About 22% of under-five children suffered from this globally [1], while in
Asia, 21,8% are suffering from stunting [1]. Indonesia is also suffering from stunting for several years.
The prevalence of stunting and severely stunting keeps above 30% (36,8%, 35,7%, and 37,2% for the
years 2007, 2010, and 2013 respectively) [2–4]. Fortunately, in the year 2018, the prevalence of stunting
decreased to 30,8% [5]. However, the number is still very high and the trend still sloping.
Although the number of stunting in children is still high, the problem of overweight and obesity has
not been solved yet. About 5,7% of under-five children are suffering from overweight in 2020, the total
number is 6 million higher than the year 2000 [1]. In the meantime, about 5% of children in Southeast
Asia region fall in the category of overweight [6]. Moreover, overweight adults globally still reach a
prevalence of 39 % [7]. The number said a lot that the strive to press the prevalence has not succeeded
yet.
Content from this work may be used under the terms of the Creative Commons Attribution 3.0 licence. Any further distribution
of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI.
Published under licence by IOP Publishing Ltd 1
Multi-sectoral policies have been constructed and implemented to end the problems of malnutrition.
However, a more comprehensive approach is still needed [8]. Until recently, the double burden of
malnutrition, particularly in Indonesia, is still occurring (under-five stunting in 2018: 30,8%; children
overweight and obese in 2018: 8%; adults with overweight and obesity: 35,4% with the female
majority [5]), which has not shown to be declining soon and still far from target (less than 30% for
under-five stunting), as shown also for adult overweight and obesity (targeting for prevalence less than
16%) [3–5]. It is an opportunity to investigate further for a more comprehensive approach to push the
high prevalence down, especially in Indonesia.
Until recently, the food consumption and repetitive infection are tend to be the direct cause of
malnutrition. Protein is one of macronutrient which essential for growth, and one comes from animal
(rather than from plant) is believed to be more beneficial for vertical growth albeit the conflicting
evidence. Animal-source protein are more complete in essential amino acids and usually carry more
energy per hundred grams. Plant-source protein often lacks on sulphur amino acids, which also essential
for protein construction in the body [9]. However, animal-source protein also tend to be more expensive
compare with plant-source protein. Therefore, some programs in overcoming stunting usually include
animal-source protein in its supplemental meals provided for the children and/or the family.
Stunting needs comprehensive and multi-sectoral solutions. Global Nutrition Report 2022 has found
that the most prominent type of nutrition action fall within the category of 'Leadership and governance'.
This type of action needs high political leadership and good governance as foundations for policies to
be effective [10]. Various approaches have been carried out in the nutrition field and others. The
Government of Indonesia recently established an effort on stunting reduction acceleration through its
Ministry of Health. The accessibility to healthy food, including sources of animal protein, become one
of its strategies. However, the policies have not yet been quite effective until recently, resulting in the
number of stunting which is still very high. This study aims to explore the efforts evolved in stunting
reduction, especially regarding access, availability, and provision of animal-based products to supply
the source of animal protein.
2. Materials and methods

The review was done narratively from scientific sources such as Pubmed and Scopus. The 193 articles
published in the last twenty years (2003-2023) were derived from the search applying keywords
“protein”, “policy”, “malnutrition”, and “stunting”, and their combination using the Boolean operator.
The final search strategy which results in the highest number of articles is "protein" AND "policy" AND
("malnutrition" OR "stunting").
The authors also apply the MeSH terms in searching articles using the Pubmed search engine. There
are 193 studies screened resulting in 159 studies excluded from 3 stages, and 40 studies in the review.
The articles were then reviewed systematically using Covidence, a web-based systematic literature
review tool, starting from its title and abstract and then followed by reviewing full text if relevant to the
research question. Since the study was a narrative review, the content of the articles included in the study
is recorded for their relevancies to the research questions and used to construct a set of information to
answer the research question.
3. Results and discussion

Stunting is the nutritional status where the height-for-age of a child falls below the -2SD based on
the WHO Growth Standard chart regarding his age and sex. Stunting is chronic in characteristic and
may result from low nutritional status which lasts for more than six months. The issue of growth faltering
receives the majority of attention during the first "1,000 days" of a child's life, while the focus diminishes
significantly when it comes to toddlers and young preschoolers. This emphasis on the early stages is
justified as it is during this time that the most rapid growth and changes in body composition occur,
along with the important transition from breastfeeding to complementary feeds and eventually to the
family/adult diet. Additionally, there is a prevailing belief that if a child becomes stunted or wasted
within the first two years, it is unlikely that they can fully recover from these conditions. [11] Identifying
undernutrition, particularly the condition of stunting, at an early stage is crucial as it allows for proactive
intervention and the prompt implementation of preventive measures, especially during the formative
2
years of childhood. [12] Macronutrients as well as micronutrients tend to have a balanced role in the
prevention of stunting. On the other hand, many studies show that protein consumption, especially which
is animal-sourced, plays a major role in the vertical growth of children. Thus its inadequacy is often
related to the large numbers of stunted
Animal Protein children.
for Stunting prevention
Studies from databases/registers (n = 197) References from other sources (n = )

PubMed (n = 184) Citation searching (n = )
Scopus (n = 13) Grey literature (n = )
Identification
References removed (n = 4)
Duplicates identified manually (n = )
Duplicates identified by Covidence (n = )
Marked as ineligible by automation tools (n = )
Other reasons (n = )
Studies screened (n = 193) Studies excluded (n = 139)
Studies sought for retrieval (n = 54) Studies not retrieved (n = 0)

Screening
Studies assessed for eligibility (n = 54)
Studies excluded (n = 14)

Wrong outcomes (n = 4)
Wrong intervention (n = 2)
Wrong patient population (n = 8)
Included
Studies included in review (n = 40)
Included studies ongoing (n = 0)

Studies awaiting classification (n = 0)
30th July 2023
Figure 1. PRISMA flowchart (derived from Covidence)
3
Numerous studies have delved into the correlation between animal-source foods (ASF) and the
growth of children. A comprehensive analysis of data conducted from 46 low- and middle-income
countries, encompassing 112,553 children aged 6 to 23 months, revealed strong links between the
consumption of ASF and child growth. These findings suggest that the high-quality proteins and
micronutrients (such as zinc, iron, iodine, essential fatty acids, vitamin B12, and other nutrients) readily
available in ASF may play a highly important role in promoting growth. Additionally, the concentrated
form of these nutrients in ASF provides a significant advantage for young children with limited stomach
capacity. Nonetheless, several studies, including both observational research and randomized controlled
trials utilizing food supplements, have yielded mixed or inconclusive results when examining the
relationship between ASF consumption and growth. Recent systematic reviews and meta-analyses have
shed light on the challenges faced in this area. Several factors such as insignificant effect sizes,
significant variations in study designs, inconsistent outcomes, and variability in sample characteristics
have all contributed to a decrease in the quality of evidence linking ASF consumption to improved
growth. [13] Nevertheless, ASF is still believed to be related to growth, especially height, in under-five
children.
The process of child growth is complex and dynamic, and changes in growth due to dietary
modifications do not happen immediately, but rather over a period of months or even years. While many
studies focus on children under 24 months old, improvements in growth can still occur long after the
1000 days. Additionally, there is still much to discover about the specific periods when certain nutrients
are most critical for consumption. The impact of diet on early life epigenetic changes, along with other
factors, may have long-lasting effects on child growth, health, and development. However, despite a
few exceptions, studies on food supplements rarely compare the relative benefits of different animal-
source foods in the same context. The importance of studying whole foods has also been emphasized,
as the non-protein components of animal-source foods may also influence growth outcomes. Moreover,
it is crucial to consider relevant household and child factors when assessing growth outcomes [13].
Another example of ASF's role in growth improvement among under-five children is also found in
Nepal. In a rural area of Nepal, a previous intervention aimed at developing the community resulted in
an increase in the consumption of Animal Source Food (ASF) and overall improved growth among
young children. Surprisingly, these positive changes occurred even though the intervention did not
specifically include any nutrition education or focus on the child's diet or health. Building on this
success, a new intervention was introduced which included a nutrition education component that
targeted children and women of child-bearing age. This education program aimed to promote diversity
in diet and encourage the consumption of ASF. Additionally, the new intervention provided training in
livestock management [13].
The efforts to prevent stunting should not only reach children under five years of age who are highly
susceptible to malnutrition but also mothers who want a baby that does not wish to fall into stunting in
the future. One of the efforts is the provision of additional food and supplementation. Some studies have
found that supplementation greatly increases the weight of the birth, but has no impact on the length of
the birth or the circumference of the head. In addition, a recent analysis of the comparison of lipids with
grain-based supplement foods in the treatment of moderate waste concluded that "more research is
needed to study the advantages of ready-to-use dairy products". [14] Unfortunately, it is still necessary
to evaluate the effects of animal protein supplements during pregnancy, premature babies, and full-term
infants/children, as well as the assessment of linear growth after birth, and systematic consideration of
variability based on several fundamental characteristics.
It has been shown that supplementation during pregnancy and infancy/childhood has a positive effect
on child weight, food-based supplementation during childhood also improves the weight-for-age scores
and reduces the risk of retardation. However, it has been shown that only the supplementation of animal-
source foods during childhood/infancy, not of formulas, increases height in age. It is important to point
out that there is a lack of high-quality studies on the linear growth results, making it difficult to draw
definitive conclusions. However, this does not diminish the benefits of balanced supplements, including
proteins and energy, in restoring the health of children with low nutrition. In addition, the potential
benefits of supplementation in cognitive outcomes should be assessed separately. [14] The World Health
4
Organization (WHO) continues to support the use of animal proteins in nutritional supplements to
address malnutrition. Despite this, further research is needed to establish solid evidence of significant
benefits beyond weight gain. Thus, future policy-related studies should give priority to investigating
these potential benefits.
The problem of malnutrition, particularly stunting, cannot be separated from the issue of food
insecurity. The lack of accessibility and availability of food is directly related to the consumption of
food, which leads to poor nutritional status. Food insecurity is a complex issue that affects the world on
a global scale. To address this problem, we need to simultaneously achieve various objectives. Firstly,
we must ensure that enough nutritious and diverse food is produced and made available to all
individuals. Additionally, these individuals must have the means to physically and economically access
this food. It is important to note that food security is closely connected to poverty alleviation and overall
health and well-being. However, it is crucial to acknowledge that agricultural production can have
negative impacts on natural vegetation and biodiversity, as well as contribute to greenhouse gas
emissions. This creates a conflict with other Sustainable Development Goals, such as protecting
terrestrial ecosystems and combatting climate change. Therefore, it is essential to understand the
synergies and trade-offs between these different sustainability objectives and how they can be influenced
by policy interventions. Scholars and policymakers have been actively discussing and researching these
topics on a global scale [15].
Animals and plants are important sources of certain vitamins, meat is a good source of B12 and green
leaf vegetables are rich in folate. However, animal products generally provide a higher amount of
minerals that can be easily absorbed by the body compared to plants. The Food and Agriculture
Organization (FAO) has introduced methods such as protein digestibility corrected amino acid
(PDCAAS) and digestible indispensable amino acid (indispensable amino acid) scores to assess protein
quality in diet. However, these indexes do not take into account the specific amino acid requirements of
tissue synthesis or the important role of amino acid synthesis in human nutrition and metabolism.
Animal-derived foods such as meat, dairy products, eggs, birds, seafood, and other foods contain more
balanced amino acids compatible with human tissue, compared to plant-derived foods such as rice,
wheat, corn, potatoes, vegetables, cereals, beans, peaches, processed soybeans, nuts, seeds, etc. For
example, beef meat has a protein content of 63-68%, whereas most plant-based foods (excluding
legumes) have only a protein content of 10-15% [16].
Efforts to enhance the quality of complementary feeding and promote a wider range of nutritious
foods have proven effective in enhancing child growth. These initiatives typically concentrate on
educating and counseling caregivers to improve their understanding, behaviors, and preferences when
it comes to providing diverse and nutritious complementary foods. However, it is important to recognize
that limited dietary diversity may also stem from challenges related to the availability, accessibility, and
affordability of food, as well as time constraints and convenience factors. Numerous studies have
highlighted affordability as a significant obstacle to consuming more nutritious foods and a deciding
factor in food choices within low- and middle-income countries [17].
In Bangladesh, India, and Pakistan, most of the household expenditure is devoted to food. In each
country, an average of 53 per cent, 57 per cent, and 45 per cent of the total expenses of households are
spent on food, respectively. Interestingly, Pakistani households spend relatively little on food, compared
to Indian and Bangladeshi households. Most of the food consumed in these countries comes from
purchases, accounting for 82% to 89% of the total food expenditure. Even in rural areas, local production
and other sources contribute less than 25 per cent of total food expenditure. In the specific food category,
cereals account for a large proportion of household food expenditure, between 21 and 27 %. Vegetables
also play an important role, accounting for between 8 and 11 per cent of food expenditure. In Bangladesh
and Pakistan, meat, fish, and eggs are widely consumed, and more than 90% of households have
consumed these foods in one to two weeks. In India, however, only about 50 per cent of households
consume these animal foods. Nuts and seeds are consumed more frequently in Bangladesh than in other
countries, while milk is consumed more frequently in Pakistan and India than in Bangladesh. In terms
of affordability, foods from animals tend to be less accessible than foods from plants. Chicken and
livestock meat (such as beef, goats, and mutton) are often one of the least affordable ways to fill the
food shortage, with a few exceptions, such as the availability of protein in Pakistan. On the other hand,
5
plant-based foods, such as legumes, nuts, and bananas, are the most affordable and nutritious options
analyzed per kilogram of calories [17].
Children under the age of five often face a range of nutrition problems, including protein-energy
malnutrition and deficiencies in essential nutrients, especially in low- and middle-income countries.
Poor dietary habits, such as consuming low-energy weaning foods, can contribute to malnutrition and
stunted growth among young children. In Indonesia, there is a wide variation in the adequacy of energy
and macronutrient intake among under-five children, indicating disparities in nutrient consumption.
Specifically, Indonesian children tend to have insufficient intake of carbohydrates and fats. However,
studies that specifically examine the adequacy of specific types of carbohydrates and fats, such as fiber
and essential fatty acids (EFAs), are rare. Consumption of EFAs, for instance, is crucial for supporting
the growth of children under the age of two. Protein is also important for linear growth, and inadequate
protein intake has been linked to higher rates of stunting. Surprisingly, more than half of the studies
included in this review reported excessive protein intake among Indonesian children. This suggests that
factors other than protein inadequacy may be contributing to child malnutrition in Indonesia. The mixed
reporting of energy and macronutrient intake also suggests that undernutrition in Indonesian children is
not solely caused by inadequate macronutrient consumption, but is likely linked to deficiencies in
essential micronutrients, which are not regularly assessed or reported [18].
Protein from animal-source recently closely related to meat from livestock such as beef, chicken, and
mutton. On the other hand, marine-source food is still rarely discussed for its role in supplying protein
from animal-source food. Aquatic foods encompass a wide range of organisms, including
microorganisms, plants, and animals, as well as innovative plant- and cell-based foods that originate
from aquatic sources. This diverse category includes various types of aquatic life such as finfish,
crustaceans like shrimp, crabs, octopus, and squids, mollusks like sea snails, cockles, and clams, as well
as aquatic plants for example water spinach and seaweed. Aquatic foods can be obtained through
farming or by being caught in the wild, and they can be sourced from different types of water bodies
such as inland lakes, rivers, and wetlands, coastal areas like estuaries and mangroves, as well as marine
environments. This broad range of sources ensures a wide variety of aquatic foods throughout the year
and across various geographic regions [19].
AASFs (Aquatic Animal Source Foods) have different manners by which they add to working on
human well-being. First and foremost, they assist with decreasing the lack of fundamental
micronutrients, for example, iron, vitamin A, and calcium, which are able to prompt different sicknesses.
Besides, AASFs are a rich wellspring of omega-3 long-chain polyunsaturated unsaturated fats, explicitly
DHA and EPA, which are useful for heart well-being, mind capability, and eye well-being. Also, AASFs
can supplant the utilization of red and handled meats, which are known to adversely affect well-being.
It is critical to take note that these pathways might cover specific people or essentially benefit explicit
populaces in light of geological area or age and orientation gatherings. The third pathway, specifically,
is connected with the sustenance progress, which happens when segment and monetary changes lead to
dietary and epidemiological movements that line up with Western food frameworks. To acquire a
superior comprehension of how AASFs can add to further developing eating regimens and general well-
being, it is important to investigate oceanic food strategy drives and ventures that plan to build
admittance to a different scope of sea-going food sources and the supplements they offer [19].
4. Conclusions
Stunting has been a health problem that leads to various consequences in the future, not only for the
children suffering from it but also for the community and the nation from a wider perspective. Stunting
has become a global burden. Stunting needs to be resolved comprehensively, with multi-sector
cooperation and collaboration as well as interdisciplinary work. Protein consumption has been
evidenced to be playing a major role in improving growth, especially vertical growth, albeit more studies
are always needed. The needs of more studies on animal protein roles in stunting prevention is due to
conflicting evidence whether it really beneficial for the linear growth of children. Protein from animal-
sourced food is considerably preferable to give a valuable supply for children's growth, due to its content
of essential amino acids, digestibility and its role in organ development. Unfortunately, consumption is
still limited, and often less than daily needs. On the other hand, protein from aquatic animal-sourced
6
food is still abundant and rarely brought into the discussion of stunting prevention. There is a promising
condition that aquatic animal source food can play a bigger role in the future to prevent stunting, as a
complementary animal protein source besides livestock. More thorough studies on availability,
accessibility, and the ratio of risk-to-benefit for stunting prevention are still highly needed.
References
[1] UNICEF, WHO, and World Bank 2021 Levels and Trends in Child Malnutrition (Geneva:
UNICEF/WHO/World Bank Joint Malnutrition Estimates)
[2] Kementerian Kesehatan Republik Indonesia 2008 Riset Kesehatan Dasar 2007 (Jakarta:
Kementerian Kesehatan RI)
[6] Southeast Asia Regional Director of the WHO 2023 Regional Director’s remarks at the launch of
the Asia and the Pacific Regional Overview of Food Security and Nutrition 2022 (Geneva: WHO)
[7] WHO 2021 Obesity and Overweight (Geneva: WHO)
[8] Peng W, Mu Y, Hu Y, Li B, Raman J and Sui Z 2020 J. Epidemiol. Glob. Health 10 16
[9] Cutroneo S, Prandi B, Faccini A, Pellegrini N, Sforza S and Tedeschi T 2023 Food Res. Int. 172
113183
[10] Development Initiatives 2022 Global Nutrition Report 2022 (Bristol: Development Initiatives)
[11] Prentice A M 2020 Nestle Nutrition Institute workshop series 95
[12] Haywood X and Pienaar AE 2021 Int. J. Environ. Res. Public Health 79
[13] Miller L C, Neupane S, Joshi N and Lohani M 2020 J. Dairy Sci. 103 9700
[14] Pimpin L, Kranz S, Liu E, Shulkin M, Karageorgou D, Miller V, Fawzi W, Duggan C, Webb P
and Mozaffarian D 2019 Am. J. Clin. Nutr. 110 410
[15] Dyngeland C, Oldekop J A and Evans K L 2020 Proc. Natl. Acad. Sci. U. S. A. 117 20511
[16] Wu G 2016 Food Funct. 7 1251
[17] Ryckman T, Beal T, Nordhagen S, Murira Z and Torlesse H 2021 Nutr. Rev. 79
[18] Arini H R B, Hadju V, Thomas P and Ferguson M 2022 Asia-Pacific J. Public Heal. 34 25
[19] Golden C D, Koehn J Z, Shepon Passarelli A, Free C M, Viana D F, Matthey H, Eurich J G, Gephart
J A, Fluet-Chouinard E, Nyboer E A, Lynch A J, Kjellevold M, Bromage S, Charlebois P, Barange
M, Vannuccini S, Cao L, Kleisner K M, Rimm E B, Danaei G, DeSisto C, Kelahan H, Fiorella K
J, Little D C, Allison E H, Fanzo J and Thilsted S H 2021 Nature 598 315

Animal Protein On Stunting Prevention A Narrative

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Animal Protein On Stunting Prevention A Narrative

Uploaded by

Copyright:

Available Formats

IOP Conference Series: Earth and Environmental Science

PAPER • OPEN ACCESS You may also like

- Modeling of toddler stunting in the

- Projecting the impact of air pollution on

This content was downloaded from IP address 80.246.30.65 on 19/01/2024 at 12:44

Animal protein on stunting prevention: A narrative review

K E Damayanti1,2*, Y L R Dewi2, B Wiboworini2 and V Widyaningsih3

*Corresponding author’s e-mail: kusmadewi@staff.uns.ac.id

2. Materials and methods

3. Results and discussion

Studies from databases/registers (n = 197) References from other sources (n = )

Studies screened (n = 193) Studies excluded (n = 139)

Studies sought for retrieval (n = 54) Studies not retrieved (n = 0)

Studies assessed for eligibility (n = 54)

Studies excluded (n = 14)

Studies included in review (n = 40)

Included studies ongoing (n = 0)

30th July 2023

Figure 1. PRISMA flowchart (derived from Covidence)

You might also like