Consumption of micronutrient-fortified milk and
noodles is associated with lower risk of stunting in
preschool-aged children in Indonesia
Richard D. Semba, Regina Moench-Pfanner, Kai Sun, Saskia de Pee, Nasima Akhter,
Jee Hyun Rah, Ashley A. Campbell, Jane Badham, Martin W. Bloem, and Klaus Kraemer
Abstract
Background. Stunting is highly prevalent in developing
countries and is associated with greater morbidity and
mortality. Micronutrient deficiencies contribute to stunt-
ing, and micronutrient-fortified foods are a potential
strategy to reduce child stunting.
Objective. To examine the relationship between the
use of fortified powdered milk and noodles and child
stunting in a large, population-based sample of Indone-
sian children.
Methods. Consumption of fortified milk and fortified
noodles was assessed in children 6 to 59 months of age
from 222,250 families living in rural areas and 79,940
families living in urban slum areas in Indonesia.
Results. The proportions of children who consumed
fortified milk and fortified noodles were 34.0% and
22.0%, respectively, in rural families, and 42.4% and
48.5%, respectively, in urban families. The prevalence of
stunting among children from rural and urban families
was 51.8% and 48.8%, respectively. Children from rural
and urban families were less likely to be stunted if they
consumed fortified milk (in rural areas, OR = 0.87; 95%
CI, 0.85 to 0.90; p < .0001; in urban areas, OR = 0.80;
95% CI, 0.76 to 0.85; p < .0001) or fortified noodles (in
rural areas, OR = 0.95; 95% CI, 0.91 to 0.99; p = .02; in
urban areas, OR = 0.95; 95% CI, 0.91 to 1.01; p = .08)
Richard D. Semba, Kai Sun, and Ashley A. Campbell are
affiliated with the Department of Ophthalmology, Johns
Hopkins University School of Medicine, Baltimore, Maryland,
USA; Regina Moench-Pfanner is affiliated with the Global
Alliance for Improved Nutrition, Geneva; Saskia de Pee and
Martin W. Bloem are affiliated with the Nutrition Service,
Policy, Strategy and Programme Support Division, World
Food Programme, Rome; Nasima Akhter is affiliated with
Helen Keller International, New York; Jee Hyun Rah and
Klaus Kraemer are affiliated with the DSM-WFP Partnership,
Sight and Life, Kaiseraugst, Basel, Switzerland; Jane Badham
is affiliated with JB Consultancy, Durban, South Africa.
Please direct queries to the corresponding author: Richard
D. Semba, Johns Hopkins University School of Medicine,
Smith Building, M015, 400 N. Broadway, Baltimore, MD
21287, USA; e-mail: rdsemba@jhmi.edu.
Food and Nutrition Bulletin, vol. 32, no. 4 © 2011, The United Nations University.
in multiple logistic regression models adjusted for poten-
tial confounders. In both rural and urban families, the
odds of stunting were lower when a child who consumed
fortified milk also consumed fortified noodles, or when
a child who consumed fortified noodles also consumed
fortified milk.
Conclusions. The consumption of fortified milk and
noodles is associated with decreased odds of stunting
among Indonesian children. These findings add to a
growing body of evidence regarding the potential benefits
of multiple micronutrient fortification on child growth.
Key words: Fortification, micronutrients, milk,
noodles, stunting
Introduction
Stunting is linear growth failure due to poor nutrition
and infections in the pre- and postnatal periods [1] and
affects nearly one-third of children under 5 years of age
in developing countries [2]. Stunting is associated with
poor child development and increased mortality [1, 3].
Stunted children do not reach their full growth poten-
tial and become stunted adolescents and adults [4] with
reduced work capacity [5]. Women who were stunted
have an increased risk of mortality during childbirth
[6] and adverse birth outcomes [7, 8].
Multiple micronutrient deficiencies are common
among poor families in South and Southeast Asia
owing to low dietary diversity and limited access to
animal-source foods. Micronutrients such as vitamin
A, iron, and zinc are important for adequate growth
of children [9]. Child stunting is a result of long-term
consumption of a low-quality diet in combination
with morbidity, infectious diseases, and environmental
problems.
Fortified foods may provide micronutrients that
are crucial to infants as they make the transition
from a diet of exclusively breastmilk to a mixed diet
that includes breastmilk and other foods. Since the
347
348
mid-1990s, fortification of powdered milk with vita-
mins and minerals has been mandatory in Indonesia,
and about one-half of instant noodles have been vol-
untarily fortified. The use of fortified powdered milk
is fairly common in Indonesia, but the use of fortified
instant noodles is less common, especially among
households in remote rural areas [11]. The relationship
between the consumption of fortified powdered milk
and fortified noodles and health outcomes has not been
well characterized.
We hypothesized that young children aged 6 to
59 months who consumed micronutrient-fortified
powdered milk and/or micronutrient-fortified noo-
dles were at lower risk for stunting. To address this
hypothesis, we examined the relationship between the
use of fortified powdered milk and noodles and child
stunting in a large, population-based sample of families
from Indonesia.
Subjects and methods
The study subjects consisted of families from rural
and urban areas that participated in the Nutritional
Surveillance System (NSS) in Indonesia from January
1999 to September 2003. The NSS was established by
the Ministry of Health, Government of Indonesia,
and Helen Keller International in 1995 [11]. The NSS
was based upon UNICEF’s conceptual framework on
the causes of malnutrition [12], with the underlying
principle to monitor public health problems and guide
policy decisions [13]. The NSS used stratified multi-
stage cluster sampling of households in subdistricts of
administrative divisions of the country in rural areas
and slum areas of large cities. Data were collected from
approximately 40,000 randomly selected households
every quarter and involved five major urban poor
populations from slum areas in the cities of Jakarta,
Surabaya, Makassar, Semarang, and Padang and the
rural population from the provinces of Lampung,
Banten, West Java, Central Java, East Java, the island
of Lombok (West Nusatenggara), and South Sulawesi.
New households were selected every round. Data
were collected by two-person field teams. A structured,
coded questionnaire was used to record data on chil-
dren aged 0 to 59 months, including anthropometric
measurements, date of birth, and sex. The mother of
the child or other adult member of the household was
asked to provide information on the household’s com-
position, parental education, and weekly household
expenditures, along with other indicators of socio-
economic status, environmental sanitation, and health.
Information was collected on the place where family
members defecated, categorized as open defecation
(river, pond, beach, bush, open space, garden), open
unimproved pit latrine, and closed (improved) latrine
(pit latrine with slab, ventilated pit latrine, flush/pour
R. D. Semba
latrine). For each child in the family, data were col-
lected on whether the child had received a vitamin A
capsule and a deworming medication in the previous
6 months. The field teams also tested a sample of table
salt from the household for the presence of iodine, as
described in detail elsewhere [14].
For each child in the family, data were collected on
whether the child had consumed industrially produced
milk products in the previous week, the brand of the
product, and how much money was spent on the milk
product in the previous week. Similar data were col-
lected on whether the child had consumed instant
noodles in the previous week, the brand of the product
(which allowed classification of noodles as fortified
or not), and how much was spent on the noodles in
the previous week. Milk products were fortified with
vitamin A, vitamin C, vitamin D, vitamin E, vitamin
K, vitamin B12, thiamin, and riboflavin. Noodles were
fortified with vitamin A, vitamin B6, vitamin B12, thia-
min, niacin, folate, and iron.
The field teams measured and recorded the weight
of each child aged 0 to 59 months with a precision
of 0.1 kg and the length/height with a precision of
0.1 cm. The birth dates of the children were estimated
with the use of a calendar of local and national events
and converted to the Gregorian calendar. Height-for-
age z-scores were calculated using the World Health
Organization (WHO) Child Growth Standards as the
reference growth curves [15]. Children with height-
for-age z-scores less than < –2 SD were considered
stunted [15].
The participation rate of families in the surveillance
system was greater than 97% in both the urban slum
and the rural areas. The main reason for nonresponse
was that the family had moved out of the area or was
absent at the time the interviews were conducted. The
rate of nonresponse because of refusal to participate
in the surveillance system was very low (less than 1%).
In each household, data were gathered regarding the
expenditures in the previous week. Expenditure and
price variables were collected in Indonesian rupiah. For
this analysis, expenditures are presented in US dollars
to control for the fluctuation of the Indonesian rupiah.
In Indonesia, monthly exchange rates from 2000 to
2003 were established with the use of historic data pub-
licly available through the Bank of Canada [16]. Mean
exchange rates by data collection round were calculated
based upon the months in which data were collected
for each round. Expenditure and price variables in US
dollars per round were created and calculated with the
use of the exchange rates by round.
The study protocol complied with the principles
enunciated in the Helsinki Declaration [17]. The field
teams were instructed to explain the purpose of the
nutrition surveillance system and data collection to
each child’s mother or caretaker and, if he was present,
the father and/or household head; data collection
Fortified foods and child stunting
proceeded only after written informed consent had
been obtained. Participation was voluntary, no remu-
neration was provided to subjects, and all subjects
were free to withdraw at any stage of the interview.
The NSS in Indonesia was approved by the Ministry
of Health, Government of Indonesia. The plan for sec-
ondary data analysis was approved by the Institutional
Review Board of the Johns Hopkins University School
of Medicine.
The study was limited to children aged 6 to 59
months because the use of fortified milk and noodles
in children under 6 months was uncommon and
exclusive breastfeeding is recommended during this
period. For families with more than one child aged 6
to 59 months, the analysis was limited to the youngest
child only (i.e., families were not counted more than
once, because stunting tends to cluster within families).
Maternal age was divided into quartiles. Maternal and
paternal education was categorized as 0, 1 to 6 (primary
school), 7 to 9 (junior high school), or 10 or more (high
school or greater) years. The proportion of mothers and
fathers with more than 12 years of education (i.e., high
school graduates) was small (2.3% and 3.8%, respec-
tively), and these parents were therefore included in
the category of those with 10 or more years of educa-
tion. Weighting was used to adjust for urban and rural
population size, by city and province, respectively, and
all results are weighted.
Weekly per capita household expenditure was used
as the main indicator of socioeconomic status. A
crowded household was defined one in which more
than four individuals were eating meals from the same
kitchen. Chi-square tests were used to compare cat-
egorical variables between groups. Analysis of variance
(ANOVA) was used to compare the adjusted prevalence
of stunting across groups by expenditure. Multivariate
logistic regression models were used to examine the
relationship between child stunting and the use of
fortified milk versus no fortified milk, the use of forti-
fied noodles versus no fortified noodles, and the use
of both fortified milk and noodles versus no fortified
milk or noodles. Models were tested for interactions
between fortified milk and fortified noodles. Variables
were included in the multivariate models if they were
significant in univariate analyses. A relationship with
p < .05 was considered significant. Covariance matri-
ces were used to examine for multicollinearity among
independent variables in the models. Data analyses
were conducted with the use of SAS Survey.
Results
In 222,250 families from rural areas and 79,940 fami-
lies from urban slum areas, the proportion of children
aged 6 to 59 months who consumed fortified milk was
34.0% and 42.4%, respectively, and the proportion of
349
children who consumed fortified noodles was 22.0%
and 48.5%, respectively. The prevalence of stunting
among children from rural and urban slum families
was 51.8% and 48.8%, respectively.
The relationship of demographic and other charac-
teristics of families from rural areas and urban slum
areas with child stunting is shown in table 1. Factors
associated with a greater proportion of child stunting
were younger child age, male sex, lower maternal age,
lower maternal education, lower paternal education,
current breastfeeding, deworming, history of diarrhea,
paternal smoking, more than four household mem-
bers eating from the same kitchen, and lower weekly
per capita household expenditure. Factors associated
with a lower proportion of child stunting were con-
sumption of fortified milk, consumption of fortified
noodles, consumption of both fortified milk and forti-
fied noodles, vitamin A supplementation, presence of
an improved latrine in the household, and the use of
adequately iodized salt. These findings were consist-
ent for families from both rural areas and urban slum
areas, except for child’s sex, which was not significant
for families from urban slum areas.
Continuous variables, such as maternal height,
weekly per capita expenditure for animal-source food,
and weekly per capita expenditure for plant food, are
compared between families with and without a stunted
child in table 2. In both rural and urban families,
maternal height and per capita expenditure on animal-
source and plant foods was significantly lower for
families with stunted children.
The relationship between consumption of fortified
milk and noodles and child stunting was examined in
separate multiple logistic regression models for families
from rural areas and urban slum areas (table 3). In
rural and urban families, consumption of fortified milk
was significantly associated with lower odds of child
stunting in separate multiple logistic regression models
after adjustment for child’s age, child’s sex, maternal
age, maternal education, maternal height, current
breastfeeding, vitamin A supplementation, deworm-
ing, history of diarrhea, household with an improved
latrine, adequately iodized salt, paternal smoking,
expenditure for animal-source food, expenditure for
plant food, household size, weekly per capita household
expenditure, and location. In rural families, consump-
tion of fortified noodles was significantly associated
with lower odds of child stunting, but the association
only reached marginal significance (p = .08) in the
multivariate models.
An interaction was found between the consump-
tion of fortified milk and fortified noodles in both
rural families (p < .0001) and urban families (p <
.0001). In rural families, the consumption of fortified
milk was associated with lower odds of child stunt-
ing when the child who consumed fortified milk also
consumed fortified noodles (OR = 0.74; 95% CI, 0.70
350 R. D. Semba

TABLE 1. Demographic and other factors in relation to stunting in children aged 6 to 59 months from families in rural areas
and urban slum areas of Indonesia
Rural Urban
Characteristica n Stunting (%) pb n Stunting (%) pb
Child consumes fortified milk Yes 75,317 43.4 < .0001 31,625 42.8 < .0001
No 145,958 56.2 42,941 53.7
Child consumes fortified noodles Yes 48,962 45.6 < .0001 38,788 45.9 < .0001
No 173,262 53.6 41,148 51.5
Child consumes both fortified milk Yes 23,153 37.7 < .0001 17,730 40.2 < .0001
and fortified noodles No 199,097 53.5 62,208 51.2
Child’s age (mo) 6–11 97,943 52.9 < .0001 34,405 50.5 < .0001
12–23 75,356 52.1 27,523 48.4
24–59 48,946 49.4 18,012 46.1
Child’s sex Male 112,869 52.4 < .0001 41,111 48.9 .39
Female 109,381 51.3 38,829 48.6
Maternal age (yr) ≤ 24 50,945 54.9 < .0001 16,222 52.7 < .0001
25–28 58,903 51.3 21,206 46.5
29–32 51,459 50.0 19,340 47.2
≥ 33 60,650 51.5 23,172 49.4
Maternal education (yr) 0 13,725 63.1 < .0001 4,211 58.6 < .0001
1–6 120,008 55.8 38,619 53.4
7–9 43,080 49.3 18,124 47.6
≥ 10 44,205 39.7 18,761 38.2
Paternal education (yr) 0 9,922 63.8 < .0001 1,849 60.3 < .0001
1–6 102,901 55.8 29,847 54.8
7–9 39,984 50.0 18,736 49.2
≥ 10 58,525 42.3 27,412 40.9
Child currently breastfeeding Yes 37,935 56.1 < .0001 13,618 56.4 < .0001
No 184,095 50.9 66,227 47.2
Child received vitamin A in past Yes 146,237 50.0 < .0001 51,187 47.0 < .0001
6 mo No 69,672 55.8 25,620 52.0
Child received deworming medica- Yes 50,569 52.4 .004 23,635 53.2 < .0001
tion in past 6 mo No 169,497 51.6 56,164 46.9
Child had diarrhea in past 7 days Yes 12,334 61.4 < .0001 5,423 57.3 < .0001
No 208,710 51.3 74,221 48.2
Household has improved latrine Yes 99,839 44.8 < .0001 63,426 47.3 < .0001
No 122,284 57.6 16,421 54.4
Household uses adequately iodized Yes 148,151 48.6 < .0001 55,705 47.0 < .0001
salt No 72,897 58.4 23,363 52.9
Father is a smoker Yes 161,420 52.8 < .0001 56,481 49.6 < .0001
No 55,672 48.6 21,881 46.6
No. of household members eating 2–4 86,267 49.4 < .0001 38,814 45.3 < .0001
meals from same kitchen >4 114,233 56.9 40,542 52.1
Weekly per capita household 1 40,106 60.6 < .0001 15,942 56.2 < .0001
expenditure, quintile 2 40,103 55.5 15,937 51.2
3 40,107 51.6 15,947 48.5
4 40,105 47.7 15,934 46.4
5 40,105 42.3 15,942 41.7
a. Missing data for variables were as follows (rural, urban): fortified milk (975, 5,374), fortified noodles (26, 4), child’s age (5, 0), child’s sex
(0, 0), maternal age (293, 0), maternal education (1,232, 225), paternal education (10,918, 2,096), breastfeeding (220, 95), vitamin A (6,341,
3,133), deworming (2,184, 141), diarrhea (1,206, 306), improved latrine (127, 93), adequately iodized salt (1,202, 872), paternal smoking
(5,158, 1,578), number of household members (21,743, 583), weekly per capita household expenditure (21,724, 238).
b. Chi-square tests are used to compare categorical variables.
Fortified foods and child stunting 351

TABLE 2. Comparison of maternal height and animal and plant food expenditures between families with and without a
stunted child — mean (SD)
Location Variable Stunted Not stunted p
Rural Maternal height (cm) 148.8 (4.9) 141.2 (4.9) < .0001
Animal food expenditures, per capita per week (US$) 0.22 (0.26) 0.27 (0.38) < .0001
Plant food expenditures, per capita per week (US$) 0.26 (0.22) 0.31 (0.26) < .0001
Urban Maternal height (cm) 148.8 (4.9) 151.3 (4.9) < .0001
Animal food expenditures, per capita per week (US$) 0.29 (0.27) 0.32 (0.29) < .0001
Plant food expenditures, per capita per week (US$) 0.32 (0.28) 0.39 (0.28) < .0001

TABLE 3. Multiple logistic regression models for consumption of both fortified milk and fortified noodles and child stunting
in families from rural and urban areas of Indonesiaa
Rural Urban
Characteristic OR 95% CI p OR 95% CI p
Child consumes fortified milk 0.87 0.85, 0.90 < .0001 0.80 0.76, 0.85 < .0001
Child consumes fortified noodles 0.95 0.91, 0.99 .02 0.95 0.91, 1.01 .08
Child’s age (mo) 6–11 1.00 — — 1.00 — —
12–23 1.03 0.99, 1.06 .09 0.94 0.90, 0.98 .003
24–59 0.94 0.91, 0.97 .0001 0.83 0.79, 0.88 < .0001
p for trend < .0001 p for trend < .0001
Male child 1.03 1.01, 1.05 .03 1.03 0.99, 1.07 .13
Maternal age, (yr) ≤ 24 1.00 — — 1.00 — —
25–28 0.88 0.85, 0.91 < .0001 0.84 0.79, 0.88 < .0001
29–32 0.86 0.83, 0.89 < .0001 0.83 0.78, 0.88 < .0001
≥ 33 0.80 0.77, 0.83 < .0001 0.77 0.72, 0.81 < .0001
p for trend < .0001 p for trend < .0001
Maternal education (yr) 0 1.57 1.46, 1.68 < .0001 1.62 1.47, 1.78 < .0001
1–6 1.44 1.38, 1.49 < .0001 1.41 1.34, 1.48 < .0001
7–9 1.22 1.17, 1.27 < .0001 1.24 1.17, 1.31 < .0001
≥ 10 1.00 — — 1.00 — —
p for trend < .0001 p for trend < .0001
Maternal height (cm) 0.902 0.900, 0.904 < .0001 0.898 0.894, 0.901 < .0001
Child currently breastfeeding 1.17 1.13, 1.21 < .0001 1.32 1.25, 1.39 < .0001
Child received vitamin A in past 6 mo 0.96 0.93, 0.99 .005 0.97 0.93, 1.01 .17
Child received deworming medication in past 6 mo 1.09 1.06, 1.12 < .0001 1.12 1.07, 1.17 < .0001
Diarrhea in past 7 days 1.30 1.22, 1.37 < .0001 1.09 1.01, 1.18 .02
Household has an improved latrine 0.81 0.79, 0.84 < .0001 0.85 0.81, 0.89 < .0001
Household uses adequately iodized salt 0.89 0.87, 0.92 < .0001 0.94 0.90, 0.98 .005
Father is a smoker 1.08 1.05, 1.11 < .0001 1.03 0.98, 1.07 .22
Plant food expenditure 0.79 0.74, 0.84 < .0001 0.86 0.79, 0.94 .0006
Animal food expenditure 0.87 0.82, 0.92 < .0001 0.78 0.72, 0.85 < .0001
> 4 individuals eating meals from same kitchen 1.09 1.06, 1.12 < .0001 1.14 1.09, 1.19 < .0001
Weekly per capita household 1 1.00 — — 1.00 — —
expenditure, quintile 2 0.97 0.93, 1.01 .14 0.95 0.89, 1.01 .09
3 0.92 0.88, 0.96 .0001 0.93 0.87, 0.99 .03
4 0.89 0.85, 0.93 < .0001 0.97 0.90, 1.04 .37
5 0.84 0.80, 0.89 < .0001 0.87 0.80, 0.94 .0005
p for trend < .0001 p for trend < .0001
Separate multiple logistic regression models were analyzed for rural and urban participants. All models were adjusted for location (province
for rural model, city for urban model).
352
to 0.79; p < .0001). The consumption of fortified noo-
dles was associated with lower odds of child stunting
when the child who consumed fortified noodles also
consumed fortified milk (OR = 0.81; 95% CI, 0.77 to
0.85; p < .0001). In families from urban slum areas,
the consumption of fortified milk was associated
with lower odds of child stunting when the child who
consumed fortified milk also consumed fortified noo-
dles (OR = 0.72; 95% CI, 0.68 to 0.76; p < .0001). The
consumption of fortified noodles was associated with
lower odds of child stunting when the child who con-
sumed fortified noodles also consumed fortified milk
(OR = 0.86; 95% CI, 0.81 to 0.91; p < .0001).
Families were divided into four categories based
upon weekly expenditure per child on fortified milk
(fig. 1) and fortified noodles (fig. 2). The prevalence
of child stunting decreased across the four categories of
expenditure on fortified milk in both rural and urban
families after adjustment for the same covariates as in
table 3 (p < .0001). The prevalence of child stunting
decreased across the four categories of expenditure
on fortified noodles in rural (p = .02) but not urban
(p = .83) families.
Discussion
The present study shows that children aged 6 to 59
months who consumed either micronutrient-fortified
milk or micronutrient-fortified noodles were less likely
to be stunted than children who did not consume
micronutrient-fortified milk. Children who consumed
60
50
Stunting (%)
40
30
20
10
0 0
0 1 2 3
Expenditure category
FIG. 1. Prevalence of stunting in children aged 6 to 59 months
from families in rural areas (black bars) and urban slum
areas (gray bars) by per capita expenditure on fortified milk.
Category 0 represents zero expenditure, while categories 1, 2,
and 3 represent the three tertiles of expenditure for families
who used fortified milk. For rural families (0, n = 158,202; 1,
n = 20,432; 2, n = 20,789; 3, n = 20,599). For urban families
(0, n = 47,042; 1, n = 10,609; 2, n = 10542; 3, n = 10,578).
Prevalence is adjusted for all covariates as in table 3. P < .0001
by ANOVA across the four categories for both rural and
urban families
R. D. Semba
both micronutrient-fortified milk and micronutrient-
fortified noodles had the lowest risk of stunting. To our
knowledge, this is the first population-based study to
show an association between consumption of fortified
milk and/or fortified noodles and reduced risk of stunt-
ing in children aged 6 to 59 months. The findings of the
study were consistent both for children from families
from rural areas and for children from families from
urban slums.
Whether the consumption of fortified milk and/or
noodles is causally related to a lower risk of stunting
cannot be definitively concluded from these results,
since the observations are based upon cross-sectional
associations from a nutritional surveillance program.
However, such a conclusion seems reasonable. There
was a graded relationship between per capita expendi-
ture on fortified milk and the prevalence of stunting.
In addition, the odds of stunting were lowest among
children who consumed both fortified milk and forti-
fied noodles.
The strengths of this study are the large popula-
tion-based sample size, the consistency of the results
between rural and urban slum areas, and data that
allowed analyses to be controlled for potential con-
founding factors. In epidemiologic studies, it is not pos-
sible to control for all factors, and unmeasured factors
may have influenced the relationship between the use
of fortified milk or fortified noodles and child stunting.
In the present study, children 6 to 59 months of age
who were still breastfeeding were at higher risk for
stunting. These findings are consistent with those of
previous studies in Uganda [18] and Nepal [19] that
60
50
Stunting (%)
40
30
20
10
0 1 2 3
Expenditure category
FIG. 2. Prevalence of stunting in children aged 6 to 59 months
from families in rural areas (black bars) and urban slum areas
(gray bars) by per capita expenditure on fortified noodles.
Category 0 represents zero expenditure, while categories 1, 2,
and 3 represent the three tertiles of expenditure for families
who used fortified noodles. For rural families (0, n = 72,922;
1, n = 49,587; 2, n = 49,399; 3, n = 49,353). For urban families
(0, n = 18,749; 1, n = 20,197; 2, n = 20,171; 3, n = 20,225).
Prevalence is adjusted for all covariates as in table 3. P = .02
by ANOVA across the four categories for rural families and
p = 0.83 for urban families.
Fortified foods and child stunting
have shown an association between prolonged breast-
feeding and stunting. By the age of 6 months, exclusive
breastfeeding is not sufficient to meet the requirements
for many micronutrients. Complementary foods con-
taining vitamin A, iron, zinc, and other micronutrients
are needed in order to meet the needs of growing
infants. The results of the present study do not apply to
children under 6 months of age who are breastfeeding.
Factors that were protective against stunting in the
present study included vitamin A supplementation
within the previous 6 months, presence of an improved
latrine, and use of adequately iodized salt. Poor sanita-
tion increases the risk of diarrheal disease and poor
growth associated with diarrhea. These findings are
consistent with those of a study in Uganda that linked
lack of a latrine in the household with child stunting
[20]. Correction of iodine deficiency has been shown
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