Key strategies to further reduce stunting in Southeast
Asia: Lessons from the ASEAN countries workshop
Martin W. Bloem, Saskia de Pee, Le Thi Hop, Nguyen Cong Khan, Arnaud Laillou,
Minarto, Regina Moench-Pfanner, Damayanti Soekarjo, Soekirman, J. Antonio Solon,
Chan Theary, and Emorn Wasantwisut
Abstract
Background. To further reduce stunting in Southeast
Asia, a rapidly changing region, its main causes need to
be identified.
Objective. Assess the relationship between different
causes of stunting and stunting prevalence over time in
Southeast Asia.
Methods. Review trends in mortality, stunting, eco-
nomic development, and access to nutritious foods over
time and among different subgroups in Southeast Asian
countries.
Results. Between 1990–2011, mortality among under-
five children declined from 69/1,000 to 29/1,000 live
births. Although disease reduction, one of two direct
causes of stunting, has played an important role which
should be maintained, improvement in meeting nutri-
ent requirements, the other direct cause, is necessary to
reduce stunting further. This requires dietary diversity,
which is affected by rapidly changing factors: economic
Martin W. Bloem is affiliated with the World Food Pro-
gramme, Rome, the Friedman School of Nutrition, Tufts
University, Boston, Massachusetts, USA, and the Johns Hop-
kins Bloomberg School of Public Health, Baltimore, Mary-
land, USA; Saskia de Pee is affiliated with the World Food
Programme, Rome, and the Friedman School of Nutrition,
Tufts University, Boston, Massachusetts, USA; Le Thi Hop
is affiliated with the National Institute of Nutrition, Hanoi,
Vietnam; Nguyen Cong Khan is affiliated with the Ministry of
Health, Hanoi, Vietnam; Minarto is affiliated with the Minis-
try of Health, Jakarta, Indonesia; Arnaud Laillou and Regina
Moench-Pfanner are affiliated with the Global Alliance for
Improved Nutrition (GAIN), Geneva; Damayanti Soekarjo is
affiliated with Santulita Vikasa Consultancy (Savica), Soekir-
man is affiliated with the Coalition Fortification Indonesia,
Jakarta, Indonesia; Surabaya, Indonesia; J. Antonio Solon
is affiliated with the Nutrition Center of the Philippines,
Manila; Chan Theary is affiliated with the Reproductive and
Child Health Alliance, Phnom Penh, Cambodia; Emorn Was-
antwisut is affiliated with the Institute of Nutrition, Mahidol
University, Bangkok, Thailand.
Please direct queries to the corresponding author: Saskia
de Pee, Nutrition and HIV/AIDS, World Food Programme,
Via Cesare Giulio Viola 68/70, 00148 Rome, Italy; e-mail:
depee.saskia@gmail.com.
S8 Food and Nutrition Bulletin, vol. 34, no. 2 (supplement) © 2013, The United Nations University.
development; urbanization, giving greater access to larger
variety of foods, including processed and fortified foods;
parental education; and modernizing food systems, with
increased distance between food producers and consum-
ers. Wealthier consumers are increasingly able to access
a more nutritious diet, while poorer consumers need
support to improve access, and may also still need better
hygiene and sanitation.
Conclusions. In order to accelerate stunting reduction
in Southeast Asia, availability and access to nutritious
foods should be increased by collaboration between pri-
vate and public sectors, and the Association of Southeast
Asian Nations (ASEAN) can play a facilitating role. The
private sector can produce and market nutritious foods,
while the public sector sets standards, promotes healthy
food choices, and ensures access to nutritious foods for
the poorest, e.g, through social safety net programs.
Key words: ASEAN, complementary foods, private
sector, public sector, stunting, undernutrition, dietary
diversity
Introduction
Stunting (short stature for age) is the result of not
meeting nutrient requirements for growth over a long
period of time between conception and 24 months of
age. The presence of stunting indicates that nutrient
intake has been suboptimal not only for growth, but
also for other critical functions of the body, such as
brain development and the immune system. Because
of the critical physical and mental development that
takes place between conception and 24 months of age,
development during this phase determines the indi-
vidual’s potential for life in terms of risks of morbidity
and mortality, school achievement, income earning
potential, physical strength, and risk of chronic dis-
ease [1]. This period is called the 1,000-days window
of opportunity. Stunting is the outcome of inadequate
nutrition during this critical developmental phase of
Key strategies to further reduce stunting in Southeast Asia
life. Because this phase does not reoccur later in life,
reversing or treating the developmental consequences
of early childhood undernutrition later in childhood
is almost impossible. Stunting and its consequences
should be prevented by ensuring access to appropriate
nutrition during the first 1,000 days of life.
The economic consequences of stunting are con-
siderable. Approximately 11% of the health burden
is related to malnutrition [2], leading to increased
healthcare expenditure at both the family and the
national levels. It is estimated that the average income
of a stunted individual is 20% lower than that of some-
one of average height [3, 4]. A conservative estimate of
the costs of malnutrition to a country is 2% to 3% of
its GDP [5].
For these reasons, stunting prevalence is a very
important indicator of the health and nutrition status of
a population, and stunting prevention is an extremely
important goal, for example, of the Scaling Up Nutri-
tion (SUN) movement [6].
In this paper we assess the trends of stunting preva-
lence over time in Southeast Asia, explore the underly-
ing causes for the trends and how they have changed
over time, and propose key strategies for a further
reduction, including recommendations that the Asso-
ciation of Southeast Asian Nations (ASEAN) can act
upon.
Trends of stunting prevalence in Southeast Asia
Figure 1 shows the prevalence of stunting in Southeast
Asian countries between 1996 and 2011. By 2011, coun-
try prevalence figures ranged from 4% in Singapore
to 48% in Laos PDR. Globally, the prevalence of child
stunting is 26%, with the highest rates in sub-Saharan
50
40
30
Prevalence (%)
20
10
0
Cambodia Indonesia Lao PDR
FIG. 1. Changes in stunting prevalence between 1996 and 2010 in Southeast Asian countries [7] with
cutoffs indicating public health problem [8]
S9
Africa (40%) and South Asia (39%) [7]. Despite con-
siderable differences among and within countries in
Southeast Asia, and the fact that in all these countries
stunting prevalence was much higher 20 to 25 years
ago, figure 1 does not show a further decline in preva-
lence in the six countries for which data are available
for three points in time between 1996 and 2011.
Figure 2 shows that Southeast Asian countries with
a higher GDP tend to have a lower prevalence of stunt-
ing. However, this does not mean that any country with
a higher GDP than another country also has a lower
prevalence of stunting. For example, Indonesia’s GDP is
more than twice that of Myanmar, but Myanmar has a
lower prevalence of stunting. Therefore, it is important
to look more closely at how GDP is related to stunting
and how GDP is distributed within a country.
Direct, underlying, and basic causes of stunting and
trends in Southeast Asia
The UNICEF conceptual framework of malnutrition
(fig. 3) shows that dietary intake and disease are the
two direct causes of stunting, because these factors
represent nutrient intake, and nutrient needs and
utilization, respectively. In turn, these direct factors
are dependent on underlying factors: access to food,
caring practices, healthcare services, and environ-
mental hygiene (water and sanitation), which are all
related to basic causes at the individual and household
levels, such as education and income, as well as societal
factors, including economic situation, gender roles,
governance, etc.
This framework helps us understand the relationship
between GDP and stunting prevalence and the observa-
tion that within a country, stunting prevalence is higher
1996–2005 2000–2006 2006–2010
Very high prevalence
High prevalence
Medium prevalence
Malaysia Myanmar Philippines Singapore Thailand Vietnam
S10 M. W. Bloem et al.

50

45 Lao

40
Cambodia Indonesia
35
Myanmar Philippines
Prevalence (%)

30
Vietnam
25

20

15 Malaysia
Thailand
10

0
0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 16,000
GDP in PPP$ (purchasing power parity $) per capita (US$)
FIG. 2. Stunting rates by GDP in PPP$ per capita in selected ASEAN countries: 2010 data [7, 9]

Malnutrition Manifestation

Inadequate Immediate
dietary intake Disease causes

Inadequate Inadequate care Insufficient health

access to for mothers services and unhealthy
food and children environment Underlying
causes

Inadequate education

Resources & control

Human, economic, and
organizational

Basic
Political and ideological superstructure
causes

Economic structure

Potential
resources

Private Bilateral
sector institutions

Multilateral institutions
Development banks
IMF

FIG. 3. UNICEF conceptual framework for the cause of malnutrition (modified by Bloem
et al. [10]).
Key strategies to further reduce stunting in Southeast Asia S11

among groups with lower socioeconomic status (see,
for example, fig. 4). Higher income improves access
to foods, healthcare, and more hygienic circumstances
and can also improve caring practices by increasing
knowledge about care and/or time available for care.
Both disease and nutrient intake can be positively
impacted by these underlying factors, and in that way
stunting can be prevented.
In order to be able to make further progress with
reducing stunting prevalence, we need to understand
which pathways are the most important in particular
contexts, so that the most suitable interventions and
strategies can be identified.
Between 1990 and 2011, mortality among children
under 5 years of age in Southeast Asia declined from
69/1,000 to 29/1,000 live births [13] (fig. 5). With
an average annual decline of 4.1%, Southeast Asia is
on track to reach Millennium Development Goal 4.
Although the number of neonatal deaths also declined
during this period, the proportion of deaths of children
under 5 years of age due to neonatal mortality increased
from 35% to 50% [13]. The drastic decline in under-five
mortality is related to the fact that healthcare services,
including antenatal care, immunization, distribution
of high-dose vitamin A capsules, and curative services
for major childhood illnesses, as well as sanitary condi-
tions and access to safe drinking water, have markedly
improved in Southeast Asia over the past 20 years [14,
15]. This also means that, while provision of healthcare
service and hygiene conditions should be maintained
and where possible improved, or its coverage should
be extended to also include the poorest, and efforts to
maintain or improve exclusive breastfeeding up to 6
months and continued breastfeeding until 24 months

50 2007 2010

40
Prevalence (%)

30

20

10

0
Urban Rural Q1 Q2 Q3 Q4 Q5

FIG. 4. Prevalence of stunting among children under 5 years of age in Indonesia according to urban or
rural location and wealth quintile in 2007 and 2010 [11, 12]

150 1990 2011

120
Deaths/1,000 live births

90

60

30

0
Brunei Cambodia Indonesia Lao PDR Malaysia Myanmar Philippines Singapore Thailand Vietnam

FIG. 5. Mortality among children under 5 years of age in Southeast Asian countries in 1990 and 2011 [13]
S12
of age should continue to be supported, further gains
in improving nutritional status should mainly come
from dietary improvements during pregnancy and
lactation and the complementary feeding period.
Meanwhile, efforts to reduce neonatal mortality will
make an important contribution to further reducing
under-five mortality.
If we look closely at nutrient requirements, many
different nutrients are required besides the ones that
are best known—i.e., energy, protein, vitamins (A, C,
D, and B-complex), and minerals (iron, zinc, iodine)—
such as essential fatty acids and essential amino acids,
growth-promoting factors in, for example, milk (insu-
lin-like growth factor), type II nutrients such as mag-
nesium and phosphorus, etc. [16, 17]. These nutrients
are required for growth of muscle tissue and bones,
brain development, and bodily functions such as the
immune system, cofactors for enzymes, etc. Because
these nutrients are present in different foods, dietary
diversity is required to meet nutrient needs [18].
Dietary diversity refers to consumption of foods
from different food groups, including animal-source
foods (dairy, fish, meat, eggs), fortified foods, veg-
etables, fruits, pulses, staple foods, oil, etc., as well
as breastmilk (exclusive in the first 6 months and
continued until at least 24 months). Also, from within
each food group, different foods need to be consumed.
Fortified foods, or home fortification with micronu-
trient powder or small-quantity lipid-based nutrient
supplements, are particularly important for meeting
requirements of specific vitamins and minerals, such
as iron and zinc, because requirements are very high
compared with feasible intakes, especially between 6
and 23 months of age [18–20].
Factors affecting diet and its relationship
with stunting
As discussed above, a diverse diet, which also includes
fortified foods, is required in order to meet nutrient
requirements and hence prevent stunting, and different
underlying and basic factors can increase access to and
consumption of a more diverse diet. The most impor-
tant underlying and basic factors, and their changes
over time in Southeast Asia, are discussed below.
Dietary diversity increases as purchasing power
improves
There is substantial evidence for the relationship
between higher dietary diversity and lower prevalence
of stunting [21–25]. Whereas Arimond and Ruel con-
trolled their analysis for socioeconomic status [21],
other analyses have shown that increased affordability
and greater expenditure on a larger variety of foods,
in particular nongrain and animal-source foods, are
M. W. Bloem et al.
associated with lower prevalences of underweight [22]
and stunting [24, 25]. An analysis of longitudinal data
on child growth from urban and rural Filipino chil-
dren collected between 1988 and 1990, showed that
the relationship between socio-economic status and
stunting emerged after the age of 6 months, suggesting
a relationship with nutritional quality of complemen-
tary foods. The relationship emerged at the age of 6–11
months among rural and 12–29 months among urban
children [26]. Together, these findings confirm that
dietary diversity, because of improved nutrient intake,
is a key link in the relationship between higher income
and lower prevalence of stunting.
Modernizing food systems
Economic development and improvements in GDP go
together with changes in the food system [27–29]. At
one end of the spectrum of food systems are agrarian
societies where the majority of the population grows
food, often as subsistence farmers; there are few pos-
sibilities to sell surplus food; there is virtually no food
manufacturing; and only a small proportion of people
buy processed foods, which are usually imported. On
the other end of the spectrum are the food systems of
developed countries, where a very small proportion
of the population grows food, most people buy their
food in supermarkets, and the distance between food
producers and consumers is long, with a large role for
food manufacturers.
As food production is modernized, yields improve,
staple food prices decline, and incomes, throughout the
population, increase. The increase in income and the
lowering of the prices of staple foods lead to increased
dietary diversity, and food systems produce a greater
variety of foods and increase food availability through
increased transport, preservation, and processing by
food manufacturers. It is important to note that many
small-holder farmers are net buyers of food, and that
their incomes improve when they gain better access to
required inputs to improve yields and reduce posthar-
vest losses, and are able to get a better price for their
produce because of better linkage to markets [15, 27].
At the same time, though, we have seen an increase in
food prices across the world since 2008, especially in
countries that import foods, which leads to decreased
dietary diversity [30]. While this process negates some
of the effects of the modernization of food systems,
both processes (modernization of food systems and
increase in food prices) occur simultaneously, but due
to other underlying mechanisms, and they affect differ-
ent countries and population groups in different ways.
Increased availability and affordability of an
increased variety of foods, including processed foods
and foods with high nutritional value, increases con-
sumer choices and convenience and has been high-
lighted as one of the major factors in the increase in
Key strategies to further reduce stunting in Southeast Asia
adult height in Europe in the second half of the 20th
century [31].
The flip side of increased choices and greater avail-
ability of a wide range of foods that contribute to an
increased intake of essential nutrients required to
prevent stunting and micronutrient deficiencies is that
the availability of foods that are calorie-dense but low
in essential nutrients (high-fat and high-sugar snacks
and high-sugar drinks) is also higher [27, 28]. Their
consumption, together with an increasingly sedentary
lifestyle, is an important factor in the obesity epidemic
and related disorders of diabetes, cardiovascular dis-
ease, and some cancers. In Asia, the poor have a higher
risk of both childhood stunting and, particularly
among adults, overweight and obesity, because their
diet tends to have a low micronutrient content as well as
a relatively high content of foods that are calorie-dense
but low in essential nutrients (e.g., white rice, refined
cereals, high-sugar and high-fat snacks, together with
few vegetables and fruits, animal-source foods, and
fortified foods) [15, 28, 32].
Urbanization
The prevalence of stunting is lower in urban than in
rural populations [26, 33] (see also fig. 4); this has also
been observed when the urban poor are compared with
the rural population, for example in Bangladesh [34].
The factors underlying this urban versus rural differ-
ence include the better employment opportunities and
hence higher income among the urban population,
better access to processed foods and animal-source
foods (greater availability, affordability, and participa-
tion in the cash economy), greater proximity to health-
care services, and higher education levels [14, 27, 28].
Parental education
Several cross-sectional studies in a wide variety of
contexts have found a relationship between higher
maternal education and better child nutritional status
[35]. Maternal education is usually an indicator of the
highest level of schooling that a child’s mother has
reached, which may have been up to 25 years prior to
giving birth to the particular child. Maternal educa-
tion can be related to several things that can positively
influence child nutrition, including income-earning
potential, a later age at marriage and first pregnancy
and therefore higher birthweight of the child, empow-
erment and bargaining power within the family for
resources and prioritizing children’s nutrition and
healthcare, and knowledge and aptitude to act on new
information related to nutrition and health. Maternal
education can also be a proxy for paternal education
and income-earning potential [36–39]. The combina-
tion of female literacy and urbanization in develop-
ing and emerging economies also increases women’s
S13
income, empowerment, and control over resources,
which can contribute to better child nutrition.
All of the above factors—purchasing power, urbani-
zation, modernization of food systems, and increased
maternal as well as paternal education—that increase
dietary diversity and thus, by improving nutrient
intake, contribute to reducing stunting prevalence, are
rapidly increasing in Southeast Asia.
Reducing the risk of stunting, targeting
different groups
As the example from Indonesia in figure 4 shows, the
prevalence of stunting varies across socioeconomic
groups, from 43.1% in the lowest wealth quintile to
24.1% in the highest wealth quintile. Similarly, over
70% of stunted and wasted children under 5 years
old live in middle-income countries, with the largest
number living in lower-middle-income countries [7].
This indicates inequality of access to economic devel-
opment and a more nutritious diet during the critical
window of opportunity, but it also shows that although
the prevalence of stunting is higher among the poor, the
wealthier are also affected. The fact that stunting occurs
in different socioeconomic groups means that different
approaches can be used to improve nutrition among
these groups. Furthermore, among the poorer quintiles
of the population, disease-related issues, such as poor
environmental hygiene and limited access to preven-
tive health services, are also still important causes
of undernutrition, in addition to diet-related causes.
Among them, both aspects need to be addressed
simultaneously, i.e., improving nutrient intake as well
as improving environmental hygiene (especially safe
drinking water and reduced environmental pollution)
and health education.
The Cost of the Diet (CoD) analysis in Indonesia
reported in the paper by Baldi et al. in this Supplement
illustrates how the prevalence of stunting is consider-
ably higher in West Timor, where few households can
afford a nutritious diet, than in urban Surabaya, where
a much greater proportion can afford a nutritious diet
[25]. The households in urban Surabaya have more
spending power, and the availability of nutritious foods
for the general population, including women of repro-
ductive age, and special nutritious foods for young
children, such as instant, fortified complementary
foods, is greater. However, the fact that nutritious foods
are more available does not automatically mean that
children in households that can afford these foods con-
sume them, and if they do, it may not be in adequate
amounts. The situation in West Timor is very different.
First of all, fewer nutrient-dense foods are available;
secondly, they cost more because of the higher costs
to transport them from where they are produced; and
thirdly, household purchasing power is much less, and
S14
in addition to that, disease-related causes are still more
important in this population as well.
Role for the private sector
In both situations described above, i.e., one where most
people can afford more nutritious foods (Surabaya)
and another where most people cannot afford them
and where their availability is also less (West Timor),
fortified processed foods can make an important con-
tribution to improving nutrient intake by pregnant and
lactating mothers and children aged 6 to 23 months.
However, the way in which people in these two situa-
tions can access such foods is different.
Figure 4 shows that stunting prevalence decreased
from 2007 to 2010 among Indonesia’s wealth quintiles
3, 4, and 5, with the largest decrease observed among
the richest, who consume the most varied diet with a
greater share of processed foods, manufactured and
marketed by the private sector. This indicates that
the households in these quintiles still need further
improvement of dietary quality in order to better meet
the nutrient requirements of their most vulnerable
members, which requires further increased availability
and accessibility of nutritious complementary foods
and awareness about their benefits. Households in the
3rd and 4th quintiles, as opposed to the wealthiest 5th
quintile, may also require improved access through
lower prices and/or greater availability in the areas
where they live.
Targeting of these higher quintiles with processed
nutritious foods and their marketing can be done by
the private sector. For these groups, the role of the
public sector is to set standards on nutritional value
and safety for such products and to increase consumer
awareness about healthy and nutritious diets.
Role of the public sector
The stunting prevalence among the lowest quintile
shown in figure 4 increased, whereas that in the
second quintile remained the same. This means that
the households in these poorest quintiles are not yet
able to afford adequately nutritious diets for their
pregnant and lactating women and young children,
while their need for an increased intake of nutritious
foods is greater than that of people in the wealthier
quintiles. They would thus benefit from the same
processed nutritious foods that are marketed to the
higher-income quintiles but would require public
sector support to be able to access them.
A good public sector distribution channel for such
special nutritious products would be social safety net
programs, which already support poor households
with cash and/or subsidized foods, such as rice for
the poor (Raskin) in Indonesia. Those programs can
either provide such special nutritious products in kind,
M. W. Bloem et al.
or they can provide vouchers to obtain these products
from local stores that also sell the same products to
other customers. In the case of distribution using a
voucher system, marketing and packaging of products
could be the same as for the consumers who purchase
the products. Also, the requirement for food standards
and raising consumer awareness about healthy, nutri-
tious foods would be the same, irrespective of which
consumer group is targeted.
The fact that the food system in Southeast Asia
already includes manufactured, fortified foods, and that
a sizeable proportion of the population already buys
such products, can be built upon to further increase
availability, lower cost, and improve nutritional quality
of foods, particularly targeting pregnant and lactat-
ing women as well as children 6 to 23 months of age.
Depending on socioeconomic status, consumers can
access such foods through existing commercial chan-
nels, or they can get access through vouchers that are
distributed by social safety net programs targeting the
poorest. Such a model of distributing vouchers for
specific foods through social safety nets and redeem-
ing them at retail outlets requires a good, preferably
electronic, registration system for the social safety net
program and a good collaboration with manufacturers
of specific products and retail outlets.
ASEAN can play a supporting role in improving
access to nutritious foods for specific target groups by
setting standards for special nutritious products and
supporting cross-border trade, and by facilitating the
sharing of experiences with development and imple-
mentation of strategies that provide access to these
foods to consumer groups with a different socioeco-
nomic status. The Business Network of SUN, which
aims to forge effective public–private partnerships for
the prevention of undernutrition, can also support the
piloting of such approaches.
Conclusions and recommendations
The major pathway for further reducing stunting
prevalence in Southeast Asia is through better meeting
nutrient requirements from an increasingly diverse
diet, including processed, fortified foods for pregnant
and lactating women and children 6 to 23 months
of age.
The modernization of food systems, increased pur-
chasing power, urbanization, and increased maternal
and paternal education levels in Southeast Asia increase
availability of and access to more nutrient-dense diets,
which are required for preventing undernutrition.
These developments, including increasing enrolment
in secondary school to increase the age at marriage of
adolescent girls, should continue.
In order to accelerate the reduction of stunting in
Southeast Asia, availability of and access to nutritious
Key strategies to further reduce stunting in Southeast Asia
products should be increased by collaboration between
the private and the public sector, and ASEAN can play
a facilitating role.
The private sector can produce and market special
References
1. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Rich-
ter L, Sachdev HS. Maternal and Child Undernutrition
Study Group. Maternal and child undernutrition: conse-
quences for adult health and human capital. Lancet 2008;
371:340–57.
2. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis
M, Ezzati M, Mathers C, Rivera J. Maternal and child
undernutrition: global and regional exposures and
health consequences. Lancet 2008;371:243–60.
3. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe
P, Richter L, Strupp B. International child development
steering group. Development potential in the first
5 years for children in developing countries. Lancet
2007;369:60–70.
4. Hoddinott J, Maluccio JA, Behrman JR, Flores R, Mar-
torell R. Effect of a nutrition intervention during early
childhood on economic productivity in Guatemalan
adults. Lancet 2008;371:411–6.
5. Horton S. Opportunities for investments in nutrition in
low income Asia. Asian Dev Rev 1999;17:246–73.
6. Scaling Up Nutrition. Available at: http://scalingupnutri-
tion.org/. Accessed 26 February 2013.
7. UNICEF. Childinfo. Monitoring the situation of children
and women. Nutritional status. Available at: http://www
.childinfo.org/malnutrition_nutritional_status.php.
Accessed 26 February 2013.
8. World Health Organization. Physical status: the use
and interpretation of anthropometry. Report of a WHO
Expert Committee. World Health Organ Tech Rep Ser
1995;854:1–452.
9. ASEAN Community in Figures 2011 (ACIF 2011).
Jakarta: ASEAN Secretariat, April 2012. Available
at: http://www.scribd.com/doc/111873404/ASEAN-
Community-in-Figures-ACIF-2011. Accessed 14 March
2013.
10. Bloem MW, de Pee S, Darnton-Hill I. Micronutrient
deficiencies and maternal thinness. First chain in the
sequences of nutritional and health events in economic
crisis. In: Bendich A, Deckelbaum RJ, eds. Primary
and secondary preventive nutrition. Totowa, NJ, USA:
Humana, 2005.
11. Badan Penelitian dan Pengembangan Kesehatan, Depar-
temen Kesehatan, Republik Indonesia. Riset Kesehatan
Dasar (RISKESDAS) 2007. Laporan Nasional 2007.
Jakarta, 2008.
12. Badan Penelitian dan Pengembangan Kesehatan,
Kementerian Kesehatan RI. Riset Kesehatan Dasar.
RISKESDAS 2010. Jakarta, 2011.
13. Levels and trends in child mortality. UNICEF-WHO-
The World Bank Joint Child Mortality Estimates.
2012. Available at: http://apromiserenewed.org/files/
UNICEF_2012_child_mortality_for_web_0904.pdf.
Accessed 26 February 2013.
S15
nutritious foods, while the public sector sets standards,
promotes healthy food choices, and ensures access to
special nutritious foods for the poorest, for example
through social safety net programs.
14. Acuin CS, Khor GL, Liabsuetrakul T, Achadi EL, Htay
TT, Firestone R, Bhutta ZA. Maternal, neonatal, and
child health in southeast Asia: towards greater regional
collaboration. Lancet 2011;377:516–25.
15. Khor GL. Food-based approaches to combat the double
burden among the poor: challenges in the Asian context.
Asia Pac J Clin Nutr 2008;17:111–5.
16. Golden MH. Evolution of nutritional management of
acute malnutrition. Indian J Pediatr 2010;47:667–78.
17. Michaelsen KF, Hoppe C, Roos N, Kaestel P, Stougaard
M, Lauritzen L, Mølgaard C, Girma T, Friis H. Choice
of foods and ingredients for moderately malnourished
children 6 months to 5 years of age. Food Nutr Bull 2009;
30:S343–404.
18. de Pee S, Bloem MW. Current and potential role of
specially formulated foods and food supplements for
preventing malnutrition among 6- to 23-month-old chil-
dren and for treating moderate malnutrition among 6- to
59-month-old children. Food Nutr Bull 2009;30:S434–63.
19. Dewey KG, Yang Z, Boy E. Systematic review and meta-
analysis of home fortification of complementary foods.
Matern Child Nutr 2009;5:283–321.
20. Nestel P, Briend A, de Benoist B, Decker E, Ferguson
E, Fontaine O, Micardi A, Nalubola R. Complementary
food supplements to achieve micronutrient adequacy
for infants and young children. J Pediatr Gastroenterol
Nutr 2003;36:12–22.
21. Arimond M, Ruel MT. Dietary diversity is associated
with child nutritional status: evidence from 11 demo-
graphic and health surveys. J Nutr 2004;134:2579–85.
22. Torlesse H, Kiess L, Bloem MW. Association of house-
hold rice expenditure with child nutritional status
indicates a role for macro-economic food policy in
combating malnutrition. J Nutr 2003;133:1320–5.
23. Rah JH, Akhter N, Semba RD, de Pee S, Bloem MW,
Campbell AA, Moench-Pfanner R, Sun K, Badham
J, Kraemer K. Low dietary diversity is a predictor of
child stunting in rural Bangladesh. Eur J Clin Nutr
2010;64:1393–8.
24. Sari M, de Pee S, Bloem MW, Sun K, Thorne-Lyman
A, Moench-Pfanner R, Akhter N, Kraemer K, Semba
RD. Higher household expenditure on animal-source
and non-grain foods lowers the risk of stunting among
children 0–59 months old in Indonesia: implications of
rising food prices. J Nutr 2010;140:196S–201S.
25. Baldi G, Martini E, Catharina M, Muslimatun S,
Fahmida U, Jahari AB, Hardinsyah, Frega R, Geniez P,
Grede N, Minarto, Bloem MW, de Pee S. Cost of the Diet
(CoD) tool: first results from Indonesia and applications
for policy discussion on food and nutrition security.
Food Nutr Bull 2013;34:S35–42.
26. Ricci JA, Becker S. Risk factors for wasting and stunting
among children in Metro Cebu, Philippines. Am J Clin
S16
Nutr. 1996 Jun;63(6):966–75.
27. Food and Agriculture Organization. The state of food
and agriculture 2013: food systems for food security and
better nutrition. Rome: FAO, 2013.
28. Schmidhuber J, Shetty P. The nutrition transition to
2030. Why developing countries are likely to bear the
major burden. Acta Agriculturae Scand Section C
2005;2:150–66.
29. Timmer CP. The impact of supermarkets on farmers,
consumers, and food security in developing countries.
In: Semba RD, Bloem MW, eds. Nutrition and health
in developing countries, 2nd ed. Totowa, NJ, USA:
Humana Press, 2008:739–51.
30. Brinkman H-J, de Pee S, Sanogo I, Subran L, Bloem
MW. High food prices and the global financial crisis
have reduced access to nutritious food and worsened
nutritional status and health. J Nutr 2010;140:153S–61S.
31. Fogel RW. The escape from hunger and premature death,
1700–2100. Europe, America, and the Third World.
Cambridge, UK: Cambridge University Press, 2004.
32. Dans A, Ng N, Varghese C, Tai ES, Firestone R, Bonita
R. The rise of chronic non-communicable diseases in
southeast Asia: time for action. Lancet 2011;337:680–9.
33. Menon P, Ruel MT, Morris SS. Socioeconomic differ-
entials in child stunting are consistently larger in urban
than in rural areas. Food Nutr Bull 2000;21:282–9.
M. W. Bloem et al.
34. Bloem MW, Moench-Pfanner R, Graciano F, Stalkamp
G, de Pee S. Trends in health and nutrition indicators in
the urban slums of three cities 
in Bangladesh, compared
to its rural areas. In: Food and Agriculture Organization.
Globalization of food systems in developing countries:
Impact on food security and nutrition. Food and Nutri-
tion Paper 83. Rome: FAO, 2004:155–68.
35. Cochrane SH, Leslie J, O’Hara DJ. Parental education
and child health: intracountry evidence. Health Policy
Educ 1982;2:213–50.
36. Semba RD, de Pee S, Sun K, Sari M, Ahkter N, Bloem
MW. Effect of parental formal education on risk of child
stunting in Indonesia and Bangladesh: a cross-sectional
study. Lancet 2008;371:322–8.
37. Chopra M. Risk factors for undernutrition of young
children in a rural area of South Africa. Public Health
Nutr 2003;6:645–52.
38. Sakisaka K, Wakai S, Kuroiwa C, Cuadra Flores L, Kai
I, Mercedes Aragón M, Hanada K. Nutritional status
and associated factors in children aged 0–23 months in
Granada, Nicaragua. Public Health 2006;120:400–11.

39. Wamani H, Åstrøm AN, Peterson S, Tumwind JK,
Tylleskär T. Predictors of poor anthropometric status
among children under 2 years of age in Uganda. Public
Health Nutr 2006;9:320–6.