Micronutrient Deficiencies and Stunting Were Associated

with Socioeconomic Status in Indonesian Children Aged

6–59 Months
Ernawati, F., Syauqy, A., Arifin, A. Y., Soekatri, M. Y. E. & Sandjaja, S. Nutrients, 2021

Pembimbing : Dr. dr. Martira Maddeppungeng, Sp.A (K)

Wanty Arruan/C175192004

TUGAS STASE BAGIAN ILMU KESEHATAN ANAK

SUB DIVISI TUMBUH KEMBANG
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
2023
ABSTRACT
Micronutrient deficiencies and stunting are known as a significant problem in
most developing countries, including Indonesia. The objective of this study
was to analyze the association between micronutrient deficiencies and stunting
with socioeconomic status (SES) among Indonesian children aged 6–59
months. This cross-sectional study was part of the South East Asian Nutrition
Surveys (SEANUTS).

2
ABSTRACT
A total of 1008 Indonesian children were included in the study. Anemia, iron
deficiency, vitamin A deficiency, vitamin D deficiency, and stunting were
identified in this study. Structured questionnaires were used to measure SES.
Differences between micronutrient parameters and anthropometric indicators
with the SES groups were tested using one-way ANOVA with posthoc test after
adjusted for age, area resident (rural and urban), and sex.

3
ABSTRACT
The highest prevalence of anemia, stunting, and severe stunting were found to
be most significant in the lowest SES group at 45.6%, 29.3%, and 54.5%,
respectively. Children from the lowest SES group had significantly lower
means of Hb, ferritin, retinol, and HAZ. Severely stunted children had a
significantly lower mean of Hb concentration compared to stunted and normal
height children.
Micronutrient deficiencies, except vitamin D, and stunting, were
associated with low SES among Indonesian children aged 6–59 months

4
 01
INTRODUCTION

5
 INTRODUCTION

Sustainable Development Goal-2 (SDG-2) aims to

eradicate the global burden of malnutrition

Both micronutrient
Malnutrition is one deficiencies and
of the primary In Indonesia, stunting can
causes of mortality in especially influence physical
children less than micronutrient and cognitive
five years of age  deficiencies and development in
mainly developing stunting. children and
countries increase the risk of
infection

6
 INTRODUCTION
A previous study in Indonesia indicated a high prevalence of anemia and
vitamin D deficiency

Almost 60% of Prevalence of Iron Prevalence of

Indonesian children deficiency levels, vitamin D
under two years old were and Vitamin A deficiency stunting is also high
reported to be anemic was 15%, 40%, and 0.9% in Indonesia

Vitamin D
Children two to five deficiency lies Riskesdas
years of age was between Malaysia almost 31% in
16.6% (47.5%) and 2018
Thailand (36.7%).

Vitamin A  the ASEAN countries,

Higher than
lowest compared to the prevalence of
Malaysia (6.6%)
Malaysia (4.4%) stunting in
and Thailand
and Thailand Indonesia is much
(13.7%).
(2.1%) higher

7
 INTRODUCTION
Many factors are known to be involved in the etiology of micronutrient
deficiency and stunting.

Previous studies in Korea and China showed that low socioeconomic

status (SES) was linked to micronutrient deficiency, including anemia,
iron deficiency anemia (IDA), and vitamin D deficiency

Sri Lanka and Bangladesh found that low SES, overcrowding, and
educated parents were associated with undernutrition among children

Therefore, the objective of this study was to analyze the association between
micronutrient deficiencies (anemia, iron, vitamin A, and vitamin D) and stunting with
socioeconomic status (SES) among Indonesian children aged 6–59 months.
. 8
 02
METHOD &
MATERIALS

9
 METHOD &
MATERIALS

• The SEANUTS in Indonesia utilized a cross-sectional study in 48 of

440 cities/districts in 2011
• A multi- stage cluster sampling, stratified for area of residence
(urban/rural), sex, and age was performed

• A total of 1008 children aged 6–59 months living in rural (57.64%) and
urban (42.36%) areas
• Blood samples for hemoglobin (Hb), serum ferritin, serum retinol, and
serum 25-hydroxy vitamin D (25OHD) were taken in sub-samples of
1008, 475, 489, and 103 subjects

• These sub-samples were chosen proportionately to represent age

groups
• Anthropometric measurements, including length and height, were
taken for 983 children because some of them refused to be measured

10
 METHOD &
MATERIALS
•Used the WHO Child Growth Standards 2006 to
Anthropometric define severe stunting (HAZ < −3) and stunting (HAZ
Data < −2).

• Anemia  Hb <11.0 g/L

Biochemical • Iron deficiency  serum ferritin <12 µg/L
Indicators • Vitamin A deficiency  serum retinol <0.70 µmol/L
• Vitamin D deficiency  25 hydroxyvitamin D <50 nmol/L

• Used national guidelines from the Central Bureau of Statistics

(Indonesia) to categorize the SES  income, education, house
Socioeconomic (type, status, and valuable goods), and electricity
Status • Calculated and categorized into five groups or quintiles, namely:
lowest, low, middle, upper middle, and upper

• Data were analyzed using SPSS version 24

• Values are presented as mean and standard deviation for
Data Analysis continuous variables or n (%) for categorical variables with p <
0.05 as significant

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 03
RESULTS

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 RESULTS

Most of the children with

lowest SES lived in rural areas
(85.4%)
Highest prevalence of anemia and
iron deficiency was found in the
lowest SES group with 45.6% and
16.4%

Highest prevalence of serum retinol deficiency was

found in the upper middle SES group with 5.5% and
vitamin D deficiency was found in the middle SES
group (60.9%)
The highest prevalence of stunting (HAZ < -2) and
severe stunting (HAZ <- 3) was found in the lowest
SES group, with 29.3% and 54.5%,

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 RESULTS

Children from the lowest SES group had significantly lower

Hb, ferritin, retinol, and HAZ

14
 RESULTS

Severely stunted children had significantly lower

Hb concentration compared to stunted and
normal height children
Children with normal height had significantly
higher retinol concentration (1.54 0.55 µmol/L)
compared to severely stunted children

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 04
DISCUSSION

16
 DISCUSSION

There was relationship between micronutrient deficiencies and

stunting regarding SES. The prevalence of anemia, iron deficiency,
stunted, and severely stunted proved highest among the lowest
socioeconomic

But not found in vitamin A and 25(OH)D deficiency prevalence

That similar to previous studies in middle and lower- income

countries where anemia is more prevalent in children from lower
SES groups

17
 DISCUSSION

Balarajan et al  32 selected low-income and middle-income countries

that conduct these surveys

SES, Children living Vtamin A (a Family income

especially in the lowest process of is considered
wealth quintile hematopoieses an important
household and mobilization of
had significantly determinant of
wealth, was lower levels of
iron in the body)
micronutrient
significantly within low SES
Hb, ferritin, group Vitamin A status and
associated retinol, and deficiency will anthropometric
with anemia HAZ than those aggravate iron indicators
in the highest status in the body
wealth quintile

18
 DISCUSSION
Chronic dietary iron
The body will take from
insufficiency will deplete
these ferritin stores if the
iron stores (mostly in the
dietary iron needs are
liver) as reflected by
not reached.
lower circulating ferritin

Iron, in the form of

ferritin, is stored in the
body

Iron depletion,
hemoglobin synthesis is
Iron-deficiency anemia affected, lowering
hemoglobin
concentration
progressively

consuming foods high in iron  animal-based foods  contains iron in

heme form, which is absorbed better than the non-heme iron form found
in plant- derived foods.
Plant-based foods, contain iron absorption inhibitors (e.g., phytate,
oxalate, and polyphenols) may cause iron deficiency and anemia in the
low SES group 19
 DISCUSSION

SEANUTS study in Indonesia, regarding food

consumption showing that animal protein and milk intake are
positively correlated to SES

Lower SES is often related to poor living conditions, such as

inadequate access to clean water and sanitation facilities,
thus increasing the risk of infection and then increasing risk of
developing anemia

20
 DISCUSSION

• Serum retinol levels in children under

five years old were higher in those who
had received supplementation
Vitamin A regularly than those who did not

• Children from the middle SES families

showed the lowest mean 25(OH)D
concentration no significant difference
25(OH)D

21
 DISCUSSION

Anthropometric Indicators

There was
Ayoya et al. HAZ significant
score <-2 and differences in the
Stunted children had mother’s anemia risk of vitamin A
A higher HAZ was
a higher risk of predicted the deficiency between
correlated with a
anemia than children occurrence of different
higher SES
with normal height childhood anemia in anthropometric
6–59 months old indicatorsstunting
children in Haiti was associated with
vitamin A deficiency

22
 STRENGTH AND LIMITATIONS
STRENGTH
This is the first study to discuss the
relationship between micronutrient
deficiencies (anemia, iron, vitamin A, and
vitamin D) and nutritional status defined by
anthropometric measurement with SES in
Indonesia, especially children under five
years old
LIMITATIONS
This study did not measure zinc in this
study and did not include analysis of data
on food intake and outdoor physical
activity; thus, it is unable to explain the
role of both behaviors concerning
micronutrient status.
23
 05
CONCLUSIONS

24
 CONCLUSIONS

Micronutrient status and

Severely stunted children
anthropometric indicators
aged 6-59 months are
have an association with
significantly associated
SES among Indonesian
with anemia
children aged 6–59 months

Anemia, iron deficiency, Doing more comprehensive

and stunting were nutrition programs to
associated with low SES improve the micronutrient
but the trend was not status of children based on
found in vitamin A SES
deficiency. While vitamin
D status shows no 25
association with SES
Thank You

26
 TELAAH KRITIS
Micronutrient Deficiencies and Stunting Were Associated with Socioeconomic
Status in Indonesian Children Aged 6–59 Months
Ernawati, F., Syauqy, A., Arifin, A. Y., Soekatri, M. Y. E. & Sandjaja, S. Nutrients, 2021

27
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30
II. KHUSUS
Menilai VIA (Validity, Importance, Aplicability)
Validity
1. Apakah awal penelitian didefinisikan dengan jelas? (pertanyaan penelitian/tujuan penelitian)
Ya, tujuan penelitian ini adalah untuk menganalisis hubungan defisiensi mikronutrien (anemia, zat besi,
vitamin A, dan vitamin D) dan stunting dengan status sosial ekonomi (SES) pada anak Indonesia usia 6–59
bulan.
2. Apakah desain penelitian dinyatakan dengan jelas?
Ya, studi Cross-Sectional di 48 dari 440 kota/kabupaten pada tahun 2011
3. Apakah pembanding dinyatakan dengan jelas?
Ya, anak usia 6-59 bulan yang tinggal di pedesaan dan perkotaan
4. Apakah faktor kausal dikemukakan?
Ya, status sosial ekonomi rendah (SES) dikaitkan dengan stunting dan defisiensi mikronutrien, termasuk
anemia, anemia defisiensi besi (IDA), dan defisiensi vitamin D
31
5. Uraian unsur PICO

Patient: 1008 anak usia 6-59 bulan yang tinggal di pedesaan dan perkotaan
Intervention: tidak ada
Comparison: Defisiensi mikronutirien dan stunting pada anak dengan status
sosioekonomi sangat rendah, rendah, menengah, menengah atas dan atas
Outcome: Pada penelitian ini dapat disimpulkan bahwa status mikronutrien dan
indikator antropometri memiliki hubungan dengan status sosioekonomi pada anak
Indonesia usia 6–59 bulan. Anemia, defisiensi besi, dan stunting dikaitkan dengan
status sosioekonomi rendah. Namun, hal tersebut tidak ditemukan pada defisiensi
vitamin A. Sedangkan status vitamin D tidak menunjukkan hubungan dengan status
sosioekonomi
32
 Importance
1. Apakah Outcome/hasil dipaparkan secara jelas (hasil uji statistic dengan hasil nilai P)
Ya, pada penelitian ini hasil dipaparkan dengan jelas serta menampilkan nilai p

2. Seberapa besar ketepatan estimasi outcome yang didapat dengan nilai OR; 95% CI?
Pada penelitian ini tidak dapat di hitung OR, RR, dan PR.

33
 Applicability

1. Apakah karakteristik pasien mirip dengan subjek yang diteliti?

Ya, karakteristik pasien di RS Wahidin mirip dengan subjek penelitian.

2. Apakah bukti ini akan mempunyai pengaruh yang penting secara klinis terhadap
kesembuhan pasien kita tentang apa yang telah ditawarkan/diberikan kepada pasien
kita?
Ya, penelitian ini memberi petunjuk mengenai adanya hubungan status mikronutrien
dan indikator antropometri dengan status sosioekonomi rendah pada anak Indonesia
usia 6–59 bulan. Anemia, defisiensi besi, dan stunting dikaitkan dengan status
sosioekonomi rendah dan anak-anak dengan severely stunted berusia 6-59 bulan, secara
signifikan terkait dengan anemia sehingga perlu dilakukan program gizi yang lebih
komprehensif untuk meningkatkan status mikronutrien anak berdasarkan status
sosioekonomi (SES) 34
Thank You
 1. Anemia Defisiensi Besi
Kelompok Umur Besi
Bayi/Anak   Inhibitor
0-5 bulan 0.3 mg
•TipsPenyerapan

 6-11 bulan 11 mg zat besi Asupan
untuk Meningkatkan dapat dihambat
Besi. oleh faktor-faktor
 1-3 tahun 7 mg khelasi besi, termasuk karbonat, oksalat, fosfat, dan fitat
 Sertakan zat besi heme dan non-heme pada waktu
 4-9 tahun 10 mg (roti
makantidak beragi,
yang samasereal tidak dimurnikan, dan kedelai).
Laki-laki
 10-12 tahun
 
8 mg
• Faktor
Sertakan
 zat
Minum
makanan
dalam
besi kopi
kaya vitamin
serat nabati C dalam makanan
dapat menghambat penyerapan
atau teh di antara waktu makan daripada
nonheme.
• saat makan
 13-18 tahun 11 mg
19-80+ tahun 9 mg Jika diminum bersama makanan, teh dan kopi dapat
  Masak makanan asam dalam panci besi cor; yang
mengurangi penyerapan zat besi hingga 50% melalui
Perempuan   dapat meningkatkan kandungan zat besi pada
pembentukan senyawa besi yg tidak larut dgn tanin (zat
 10-12 tahun 8 mg makanan hingga 30 kali lipat.
13-18 tahun 15 mg
antinutrisi).



19-49 tahun
50-80+ tahun
18 mg
8 mg
• Zat besi dalam kuning telur kurang diserap karena adanya
phosvitin.
Hamil trimester 2 dan 3 + 9 mg
Menyusui +0

Ellie Whitney, 2019; Kemenkes, 2019.

 • Serum retinol levels in children under five
years old were higher in those who had
received supplementation regularly than
Vitamin A those who did not

• Children from the middle SES families

showed the lowest mean 25(OH)D
concentration no significant difference 
small sample size, particularly the smaller
25(OH)D sub-samples for serum vitamin D analysis

21
 Definisi Anemia
 Kondisi kadar hemoglobin dalam
darah lebih rendah daripada standar
(kurang dari normal)
 Kadar hemoglobin normal berbeda
pada tiap jenis kelompok umur
 Terjadi ketika produksi hemoglobin
menurun
 THALASEMIA 1.Konsumsi Fe <
MALARIA 2.Penyerapan Fe <
DLL
3.Kebutuhan Fe
HEMOLITIK meningkat
4.Kebocoran/
Defisiensi Perdarahan
Zat besi
Defisiensi
ANEMIA Zat Gizi Defisiensi
Non Vit B 12
Zat besi
NON Asam Folat
HEMOLITIK
Kerusakan
Non sum-sum Tlg
Defisiensi
Zat besi
DLL
 Klasifikasi Anemia
WHO
cut off point values untuk menentukan Anemia
- laki-laki dewasa : < 13 g/dl
- perempuan dewasa : < 12 g/dl
- wanita hamil : < 11 g/dl
- balita (6 bl- 5 thn) : < 11 g/dl
- anak (6 thn – 14 thn) : < 12 g/dl
Berlaku untuk orang yang tinggal ditempat dengan ketinggian
sejajar dengan permukaan laut,
Semakin tinggi tempat, kadar Oksigen makin rendah 
standar kadar Hb lebih tinggi
 Jenis Anemia
ANEMIA BESI
ANEMIA ASAM FOLAT
ANEMIA B12

Penentuan anemia menggunakan parameter Hb, akan tetapi untuk menentukan

jenis anemia diperlukan pemeriksaan mikroskopis (bentuk hapusan sel darah
merah)
Pemeriksaan mikroskopis anemia
Jenis Anemi Fe Anemi Folat Anemi B12

Bentuk sel mikrositik makrosisitik makrositik

Warna sel hipokromik hiperkromik hiperkromik

 DISTRIBUSI ANEMIA
ANEMIA Fe ANEMIA ANEMIA B12
FOLAT
Balita, ibu Fase Vegetarian
hamil, ibu pertumbuhan, yang ketat,
menyusui dan sosek rendah gangguan
WUS absorbsi,
cacing
Diphyllobotrium
Latum,
konsumsi PAS
(Para Amino
Salicill acid)