What is the important thing

about stunting ?

JC SUSANTO
 INTRODUCTION
 Stunted define as:
 HAZ < -2SD (WHO child growth standards)
 Severe stunted  <-3 SD
 Stunted is not only short stature
 Families & health worker often ignore to asses linear growth
because linier growth is not routinely measured as part of
community health programmes.
 Assessment of linier growth is essential for determining
whether a child is growing adequately, or a has a growth
problem or tendency to ward a growth problem that should
be addressed (deOnis 2016)
 INTRODUCTION
 Accuracy & reliability of length/height depend
on:
 Robustness
 Precission maintenance
 Calibration of the anthropometric equipment

Length board
(typically for under 2 years old)a
Stadiometer/height board
(typically for children 2 years or
older )b

Sumber:
a
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/measuring_children.html
b http://pediatriccare.solutions.aap.org/data/Books/1017/m_chp14_F015.jpeg
Adoption of the WHO Child growth standard to
classify Indonesian children under 2 years of age
• The WHO child growth standard a better tool for assesing the
nutritional status of Indonesian children than WHO/NCHS.
• However low WAZ is not suitable indicator for commencing
an extra feeding program, because it reflects stunting instead
of wasting
• The high prevalence of stunting indicates the need to
perform preventive nutritional intervention beginning early
in life. (Julia M. Food and Nutritional Bulletin 2009).
 PROBLEM IN DEVELOPING COUNTRIES

 Un-hygiene environment
 Reccurent infections
 Drink contaminated water
 Expose smoke polutions Growth faltering
 Food containing fungal & Loss of growth
bacterial toxin
 Insufficient diet during
convalescence period after
sick
 PREVALENCE

 The number & percentage stunting  in Global, Latin America,

Carribean, Asia
 Increase in Africa & Indonesia
(Riskesdas: 2007-2013 (36,8%  37,2%)
 PREVALENCE IN INDONESIA
1993 2007
Underweight 34,5% 21,4%
Stunting 50,8% 36,7%
STUNTING IN 2013
Vietnam 23,3%
Phillipine 35,1%
Myanmanr 35,1%
Malaysia 14,2%
Indonesia 37,2 %
Ethiopia 44,2%
Afganistan 59,3%

Sumber: Rachmi CN, Agho KE, Baur LA. Stunting, Underweight and Overweight in Children Aged 2.0–4.9 Years in
Indonesia:Prevalence Trends and Associated Risk Factors. PlosOne. 2016
 STUNTING: Genetic and environment
 Although height is on of the most heritable human
traits, across population differrences are believed to be
related to non genetic and environment factors.
 Of these foetal growth and nutrition and infection
during childhood and adolescent are particularly in
potent determinant of height during childhood.

NCD Risk factor Collaboration, eLIFE, 2016.

 STUNTING: in early life
 The earlier the age at which a child is identified to be
stunting, the easier and more rapid is the reversal of
stunting.
 It is wrong to think that after the age of 2 or three year
tratment is totally ineffective
 To prevent stunting this improvement must occur over
the time the child is actively stunting, (the first 2 years
of life)
NCD Risk factor Collaboration, eLIFE, 2016.
 STUNTING: in early life
 Increasing the energy density alone has no effect on
stunting but does increase the child’s fat mass.
 Preventive intervention should be strongly focused on
the young child, certainly below the age of 2 years and
preferably from birth, but treatment should be offered
to all stunted children irrespective of their age.

NCD Risk factor Collaboration, eLIFE, 2016.

 Stunting and Stunted
 In the young child growth in height is sufficiently
rapid.
 It is miss-leading to think of “stunting” as a chronic
process, it is an active, cumulative, ongoing
condition.
 Stunting is “the process” while stunted is the end
result of the process.
 The stunted child as having “persistent malnutrition”
rather than “chronic malnutrition”
Hambatan pertumbuhan BB diikuti hambatan pertumbuhan PB
Growth faltering in HEIGHT is following growth faltering in WEIGHT
 C 0 bln 6 bln 12 bln 24 bln

20% 20% 50% 10%

Kebutuhan kalori 600 kkal 800 kkal 1100 kkal
Kecukupan Kalori dg
60-70% 30-40%
ASIX
Tambahan kalori 200 kkal 300 kkal 550 kkal
Lemak
50 % 30-45% 30-35%
C
Birth; 3 kg 9,6 kg 12 kg
50 cm +24 cm +12 cm
12 bulan 24 bulan
 Catch-up growth at 6 months of age
 Children over the age of 6 months have the potential to gain
height at a rate that is at least three times the normal rate of
height gain.
 A child under 1 year of age can gain 1 z-score unit in 2 to 4 weeks.
 The severely stunted (HAZ <-3SD), 6 months old child could fully
return to normal height (0 z-score) in about 6 months.
 To prevent the process of stunting from continuing will require a
sustained change in the child’s usual nutrition

Golden MH, FNB 2009.

 Once stunted always stunted
• Poor nutrition  stunted, begin in utero and continue
to infancy and early childhood.
• Recovery of at least some of the deficit if possible if
the child’s environment is improved through nutrition
and health intervention or through adoption. (Keeton
2015).
 What is the cause of stunting ?

 Understanding the causes include approaching from the

basic, underlying & immediate levels
 Important to know the timing of stunting
 The causes are  insufficient macro & micronutrient
 The consequences are  transgenerational, impact
individual, community & national level
 What is the cause of stunting ?
• Delayed initiation
Inadequate • Not breastfed (BF) at all
breastfeeding • Not exclusive BF
• Early cessation BF
• Poor quality food  low density energy&
nutrition, Inadequate micronutrient ( low
Inadequate diversity, limited animal source food, high
antinutrient  polivenol, phytate)
complementar • Inadequate practice (infrequent, dilute feed
y feeding  low density energy, inadequate feeding
during illness )
• Unsafe water and food  infection
What is the cause of stunting ?

1. Low density  Need

LARGE volume to meet
energy requirement
2. Limit stomach volume
capacity
 What is the cause of stunting ?

 Breastfed infant typically consume relatively small amount of

food other than breastmilk  complementary food need to be
high in nutrient density
 Iron & zinc  important and high concentration in ASF
 Diet base on grain & legume  high phytat  antinutrition
 Bangladesh, Ethiopia and Vietnam  theoritically unfortified
food alone is enough, BUT this was possible only if liver were
consumed daily.
 Feeding practice in Indonesia
Indonesian recommendation, 1995

 Eat a wide variety of foods

 Consume iron-rich food
 Consume foods  sufficient
 Breastfed exclusively for 4
energy
months
 Half of total energy from
 Eat breakfast
complex carbohydrate-rich
 Drink adequate quantities of
food
fluids  free from
 Not > ¼ of energy from fats
contaminants
or oils
 Do physical activity regularly
 Use only iodized salt
 CF recommendation 9-16 mo in East Lombok, Indonesia
1.Breastfeed daily on demand
2.Give your child boiled
drinking water
3.Feed  main meal 3 x/day ;
snacks 2 x/day
4.Protein source food from
plant or animal sources in
each main meal
5. Add shredded chicken, liver/fish or
dried anchovy in each main meal 
iron, zinc and calcium
6. Feed vegetables daily; vegetable
prepared with protein source foods
are encouraged
7. Choose nutrient dense snacks such
as fortified biscuit or homemade-
snack made from fish, chicken liver
or anchovy.
Kecuku
pancair
an
Tumpeng gizi & 4 sehat 5 sempurna
Food plating and food guide pyramid
 International reccomendations VS Indonesian recommendation

 WHO 2003 :  INDONESIA 2014:

 Adult  fat <30%  LOW FAT in all ages (including
 Children 2-18 yo  fat 30-35% infants & children
 Indonesian recommendation VS International recomendations

 Uauy 2000 :
 Children aged 8-24 mo can’t grow if they only consume
fat < 22% & low animal source food
Important characteristic of diet appropriate children
with moderate malnutrition
High content of micronutrients, especially growth (type II) nutrients
High energy density
Adequate fat content
Appropriate fat quality, especially n-3 / n-6 PUFA
Content of some animal source foods
Low content of anti nutrients
Low risk of contamination
Acceptable taste and texture
Culturally acceptable
Easy to prepare
Affordable and available

(Michaelson KF., 2009)

 Indonesian recommendation VS International recomendations

Sumber: WHO, Guiding principles for complementary feeding of the breastfed infants. 2003
 Consequence of stunted growth
Table 1. Conditions associated to stunting in children and adults

Sumber : Branca F., Ferrari M. Impact of micronutrient deficiencies on growth: the stunting syndrome. Ann Nutr Metab
2002;46(suppl 1):8–17
Sumber: Guerrant et al. The impoverished gut-a triple burden of diarrhea, stunting, and chronic diasease. Nat Rev Gastroenterol Hepatol. 2013
April ; 10(4): 220–229
 Figure. The vicious cyle diseases and poverty
Sumber: Guerrant et al. The impoverished gut-a triple burden of diarrhea, stunting, and chronic diasease. Nat Rev Gastroenterol Hepatol. 2013
April ; 10(4): 220–229
Intergenerational consequences
Linear Growth Retardation (Stunting) and Nutrition, Uauy, 2008
 10 %
Stunted and brain development
90 %
MALNUTRITION HINDERS COGNITIVE ACTIVITY
OLD THEORY
MALNUTRITION BRAIN DAMAGE DELAYED INTELLECTUAL
DEVELOPMENT
NEW THEORY BRAIN DAMAGE
(SOMETIMES REVERSIBLE)
LETHARGY AND MINIMAL
WITHDRAWAL EXPLORATION
OF ENVIRONMENT DELAYED
INTELLECTUAL
MALNUTRITION ILLNESS DEVELOPMENT
DELAYED DEVELOPMENT
OF MOTOR SKILLS SUCH AS
CRAWLING AND WALKING LOWERED
EXPECTATIONS OF
CHILD FROM ADULTS
BECAUSE CHILD
APPEARS YOUNG

DELAYED PHYSICAL
GROWTH
POVERTY
LACK OF EDUCATIONAL
AND MEDICAL RESOURCES
 Double burden of malnutrition

Figure . The transition from intergrational malnutrition to abdominal adiposity and diabetes

Sumber: James WO. Will feeding mothers prevent the Asian metabolic syndrome epidemic?. Asia Pasific J Clin Nutr. 2002. 11(Suppl): S516–S523
 Figure. The stunting syndrome
Sumber : Prendergrast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatrics and International Child Health. 2014.34(4): 250-265
 Malnutrition & immune function

Sumber:Bourke CD, Berkley JA, Prendergast AJ. mmune dysfunction as a cause and consequence of malnutrition. Trends in
Immunology. 2016, Vol. 37, No. 6
 Prevention of stunting
Stunting  not treatable
PREVENTION

Adequately nourished pregnant &

Exclusive BF up to 6 mo Adequate CF 6-23 mo
lactating mother

Preventive strongly focused in the first 2 y of life

 Prevention of stunting
Individu needs approximately 40 different nutrients
Important characteristic of diet appropriate for moderate malnutrition/stunting :

 High content of micronutrient, especially  Content of some animal source food

growth nutrient (type II).  Low content of anti nutrients
 High energy density  Low contamination
 Adequate protein content  Acceptable taste and texture
 High protein quality and availability  Easy to prepare
 Adequate fat content  Affordable and available
 Appropriate fat quality, especially n-3/n-
6 PUFA content

Sumber : Michaelsen KF, Hoppe C, Roos N, et al. Choice of foods and ingredients for moderately malnourished children 6
months to 5 years of age. Food Nutrition Bulletin 2009, 30: s343-s404.
 Why fat ?
 Important source of energy for infant & young children
 FACTS : Human milk contain 50% energy from fat  FAT is
important in early life
 Recomendations CF:
 Not malnourished : fat 30-45% of total energy including from
breastfeeding
If the diet contain NO animal source food  recommend to add 10-20 gr
of fat
• Moderate stunting : fat at least 35% of total energy
 The wasted child should be able to replenish both the lean and the fat tissues within a
reasonable period of time to reach the normal range of weight-for-height

Sumber: Golden MH. Proposed recommended nutrient densities for moderately malnourished children. Food Nutrition
Bulletin 2009; 30: s267-s342
GROWTH
 Increase 1 cm in Height  weight
gain about 210 gram
 Nutrient potentially needed in higher
amount for skeletal than lean tissue
include:
 Sulfur, phosphorus, calcium,
magnesium, vitamin D, vitamin
K, vitamin C and copper
 To gain 5 gr/kgBW/day  need
calories 200 kkal/kgBW
Black 2013, Conceptual framework to prevent stunting
Nutrient specific consist of:
 Adolescent pre pregnancy: malnutrition, micronutrient deff, prematurity, still birth & asphyxia
 Pregnancy: malnutrition, micronutrient deff, anorexia, low birth weight, asphyxia
 Newborn: Delayed cord clamping, Breast crawl/IMD, Rooming in
 Infant 0-6 mo: Exclusive BF, Predominant or partial BF and NOT BF at all, BF in the work place
 Complementary feeding : Too early and too late. Low density energy and nutrition, Taboo, Low
education of care giver, National recommendation (low fat diet for all people, and high anti nutrient)
 Infection : frequent & reccurent infection
 Environmental enteropathy
 Growth monitoring and Growth monitoring and promotion: Misuse of growth chart
NOT for growth monitoring (or growth monitoring and promotion) BUT for nutrition status measurement 
LATE INTERVENTION !
Optimum fetal and child nutrition & development

Sumber: Black et al. Maternal and child nutrition. Lancet. 2013

Sumber: Black et al. Maternal and child nutrition. Lancet. 2013
WHO
2013

Sumber: WHO. Childhood Stunting: Context, Causes and Consequences.. 2013.

 C 0 bln 6 bln 12 bln 24 bln

20% 20% 50% 10%

Kebutuhan kalori 600 kkal 800 kkal 1100 kkal
Kecukupan Kalori dg
60-70% 30-40%
ASIX
Tambahan kalori 200 kkal 300 kkal 550 kkal
Lemak
50 % 30-45% 30-35%
C
Birth; 3 kg 9,6 kg 12 kg
50 cm +24 cm +12 cm
12 bulan 24 bulan
 Sonia Blaney commented:
 The Indonesian RDAs are different from the current International
WHO/FAO/UNU recommendation in term of energy, protein, vitamin
and mineral requirement
 Overall feeding practice were not optimal among Indonesian children
from six months of age and upwards.
 Children do not eat enough, and that consumption of micronutrient rich
food is limited, but cunsumption of tea and coffee – which can limit
absrption of Ca and Iron, about 29% and 56% of children.

Blaney S. Feeding practices among Indonesian children above six months of age (1). Asia
Pas J Clin Nutr 2015.
 CONCLUSION

 Incidence of stunting in Indonesia is still high.

 From 2007-2013 increasing from 36.8% to 37.2%.
 The cause is nutrition (pre-natal & post-natal), infection and
environment factors, growth monitoring, poverty problem,
management of malnutrition.
 Nutrition factor  could possibly because of national diet
recommendation has low quality, especially in complementary food
Thank you