STUNTING DI PESISIR SULAWESI

TENGGARA: FAKTOR DETERMINAN

DAN UPAYA PENAGGULANGANNYA

Devi S Effendy, Ph.D

OUTLINE
EPIDEMIOLOGI, DAMPAK, DAN
FAKTOR DETERMINAN STUNTING
STUNTING SEBAGAI ISU
KESEHATAN MASYARAKAT DI
PESISIR SULAWESI TENGGARA
CONTOH INTERVENSI UNTUK
MENURUNKAN STUNTING DI
WILAYAH PESISIR SULTRA
 APA ITU STUNTING?

• Diidentifikasi dengan menilai panjang

badan (unt anak usia < 2yr) atau tinggi
badan (unt anak usia >2 yr)
• Hasil ukur dibandingkan dgn nilai baku
standard: WHO CHILD GROWTH
STANDARD
• Stunted jika PB atau TB anak <-2 SD
median baku standard untuk usia dan jenis
kelamin yang sama
 BAGAIMANA CARA MEMBEDAKAN ANTARA
STUNTING DAN NON STUNTING
a. 2 anak dengan tinggi yang sama (86 cm) b. WHO Standard

De Onis, M., & Branca, F. (2016). Childhood stunting: a global perspective. Maternal & child nutrition, 12, 12-26.
 PENGUKURAN PANJANG BADAN ANAK USIA <2 YR: POSISI KAKI ANAK DAN
TANGAN PETUGAS

De Onis, M., & Branca, F. (2016). Childhood stunting: a global perspective. Maternal & child Photo taken at Posyandu Dian, Bina Bersama, in Kendari City14 Noveber 2018
nutrition, 12, 12-26.
 GLOBAL SITUATION OF STUNTING

Percentage of children
stunting affects 1 in every 3 children
under 5 affected by
stunting, by country,
20201
≥30% (very high)

20 – <30% (high)

10 – <20% (medium)

2.5 – <10% (low)

<2.5% (very low)

Modeled estimate
not available

TARGET GLOBAL: PENURUNANA 40 % JUMLAH ANAK BALITA STUNTING PADA TAHUN 2025
 Percentage of children
Stunting Situation in 0-59 months of age with Southeast
Indonesia LAZ <-2 SD in 2015
South & Sulawesi
middle
Sumatera Kalimantan

Prevalence of stunting in Papua

children in Indonesia in
2007-2018

36,8 35,6 37,2 30.8%

% % %

20-<30 % 30-40 %
2007 2010 2013 2018 NTT & NTB
Still high in some
areas in Indonesia
 CONCEPTUAL CAUSAL MODEL OF CHILD STUNTING

Published in: Emily Mosites; Elizabeth Dawson-Hahn; Judd Walson; Ali Rowhani-Rahbar; Marian L. Neuhouser; Paediatrics and International Child Health Ahead of Print
DOI: 10.1080/20469047.2016.1230952
Copyright © 2016 Informa UK Limited, trading as Taylor & Francis Group
• Child stunting is associated with the following determinants in Indonesia: male sex,
premature birth, short birth length, nonexclusive breastfeeding for the first 6 months,
short maternal height, low maternal education, low household socio-economic status,
living in a household with unimproved latrines and untreated drinking water, poor
access to healthcare, and living in rural areas.

• Evidence is lacking for low education; society and culture; agriculture and food systems;
and water, sanitation, and the environment contribute to child stunting.
 Timing of Growth Faltering, 54 DHS survey

Children are born w/

weight & length that are
close to standard

PB/U decline until

around 24 months

Continues to falter in
height
poor environments
beyond 2 yr

Post natal
Intervention time
Cesar Gomes Victora et al. Pediatrics
2010;125:e473-e480 ©2010 by American Academy of Pediatrics
 Timing of Growth Faltering in Indonesia

Saat lahir sampai 5 bulan rate

stunting ad 20%
Proses gagal tumbuh dimulai
sejak masa prenatal

Rate stunting meningkat

mencapai >50% pada usia 18-
23 mo
20 %
Julia M. Adoption of the WHO Child Growth Standards to Classify Indonesian
Children under 2 Years of Age According to Nutrition Status: Stronger Indication
for Nutritional Intervention. Food and Nutrition Bulletin. 2009;30(3):254-259.
doi:10.1177/156482650903000306

Stunting dimulai sejak dalam kandungan dan berlanjut sampai paling tidak usia 2 tahun pasca
lahir—masa hamil dan masa awal kehidupan menjadi penting dlm terjadinya stunting
 IMPACT OF STUNTING

The cause of death

Cognitive impairments

Increased risk of chronic disease

Loss of physical growth potential

 The Leading Causes of Death Worldwide
Undernutrition 45 % kematian pd anak < 5 death in
2011 & stunting cause 14 %-17% of death (Black RE et al, 2013)
percentage
others Pneumon
diseases2 ia 18,3%
3.8 diare
10.5 %
malaria
7.4%

neonatal
death 40Pneumonia Diare Malaria
%

Mortality in severely stunted

is >5x than in well nourished

Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, et al. (2013) Associations of
Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five
Years: A Pooled Analysis of Ten Prospective Studies. PLOS ONE 8(5): e64636.
doi:10.1371/journal.pone.0064636
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0064636
 Cognitive
Stunting
Impairment

Reduce adult Poor School

stature Achievement

Reduce adult
earnings

Poverty

Maternal & Child Nutrition

pages 5-18, 19 SEP 2011 DOI: 10.1111/j.1740-8709.2011.00349.x
Undernutrition mempengaruhi struktur & fungsi otak Corderoetal.1993
STUNTING SEBAGAI ISU KESEHATAN MASYARAKAT
DI WILAYAH PESISIR SULTRA
STUNTING DI SULAWESI TENGGARA

37.2 % 30.8 % 27.7 %

2013 2018 2019

STUNTING DI SULAWESI TENGGARA

37.2 % 30.8 % 27.7 %

2013 2018 2019

 STUNTING DI WILAYAH PESISIR KOTA KENDARI
Percentage of Wasting, Stunting and
Underweight
35.00%

30.80%
30.00% waz < -2SD

25.00% 10.70%
19.60%
20.00% 18.50%
Percentage

15.60% age 6 - 11
15.00%
age 12 - 17 89.30
11.20%
%
10.00%
6.70%
5.00%

normal stunting
0.00%
whz < -2 SD haz < -2 SD waz < -2SD
Nutritional status Effendy, D. S., Prangthip, P., Soonthornworasiri, N., Winichagoon, P., & Kwanbunjan, K.
(2020). Nutrition education in Southeast Sulawesi Province, Indonesia: A cluster
randomized controlled study. Maternal & child nutrition, 16(4), e13030.
DETERMINAN STUNTING DI PESISIR SULTRA:
1. BERAT BAYI LAHIR RENDAH
 BBLR
17

151

148
149

142

74
14
5
64

59

Dinkes prov sultra, 2018

BBLR mempunyai asosiasi
dengan stunting
2. ASUPAN MAKAN YG TDK ADEKUAT:
Rendahnya dietary diversity pada anak
STUNTING PADA KELOMPOK RENTAN ANAK USIA 6-24 DI SULTRA

PERCENTAGE OF STUNTING AT
AGE 6 TO 23 MOTHS IN SE
SULAWESI PROVINCE

Stunting pada anak usia 6 - < 2 yr 25.50%

25.00%
24.50%
24.00% 25%
23.50%
23.00%
22.50%
22.00%
Complementary feeding 21.50% 21.9 %
21.00%
period 20.50%
20.00%
2013 2018
Year
RISKESDAS, 2018
 KARAKTERISTIK USIA 6-24 Mo DAN MP-ASI
Susceptibility to infection
Rapid
growth
Fully High nutritional
dependent on need
other
 CHILD DIETARY DIVERSITY DI SULTRA
80.00%
75.3o
70.00%

60.00% High percentage

53.45
of children with
50.00% 46.60%
low quality of
Axis Title

40.00%
food
30.00%
24.70% SE
20.00%
Sulawesi
Barrier to the best
10.00%
achievement of
0.00%
children's nutritional
MDD> 4 MDD < 4 group status in this area
Percentage of children achieving MDD
 INDIKATOR COMPLEMENTARY FEEDING DI WILAYAH PESISIR KOTA KENDARI
% of children meetting WHO recommendation at baseline

90.00%
84.50%

80.00% 77.00%

70.60%
• MEAN DDS 2.3
70.00%
• SEMUA INDIKATOR
60.00% 56.00%
MENUNJUKAN
50.00%
RENDAHNYA POLA
40.00%
PEMBERIAN MAKAN
30.00%
PADA MASA
20.00% 17.50%
15.50%
12.10% 11.10% PENYAPIHAN
10.00%

0.00%
MDD MMF MAD Continue breastfeeding

Control Intervention

MMD: minimum dietary diversity; MMF: minimum meal frequency; MAD:

minimum acceptable diet
 KONSUMSI KELOMPOK MAKANAN PADA MASA MP-ASI DI AREA PESISIR KOTA
KENDARI
120.00% % of consumption of food group at baseline % of consumption of selected food
60.00%
at baseline
97.60% 54.80%
54.30%
98.30%
100.00%
50.00%

80.00%
40.00%

60.00% 54.30% 30.00%

49.20%

40.00% 30.20% 20.00%

32.50% 16.40%
14.30%
25.40% 24.10%
17.20%
20.00% 10.00%
6.90% 15.90% 12.70%
4.30%4.00%
4.00% 4.30%
0.00% 0.00%
Grains, roots, Legumes and Milk Flesh Food Eggs Vitamin A-rich Other fruits Fruits Sweet and salty Healthy snacks
and tubers nuts fruit and and vegetables snacks (processing
Control group Intervention group
snack)
vegetables
Control group Intervention group
• Dietary diversity
berhubungan
signifikan dengan
stunting
• Konsumsi animal
food menurunkan
risiko menjadi
sunting
• Anak yang masih
menyusui
cenderung
mempunyai DD
rendah

DD AD KONTRIBUTOR UTAMA PERTUMBUHAN DAN PERKEMBANGAN ANAK

3. MORBIDITAS PADA ANAK
 RIWAYAT MORBIDITAS ANAK DLM 1 BULAN TERAKHIR

Control Intervention
(n = 116) (n = 126)
n (%) n (%)
Child morbidity at baseline
Getting a Fever in the last 1 month 85(73.3) 96(76.2)
Getting common cold in the last 1 month 54(46.6) 62(49.2)
Getting diarrhea in the last 1 month 22(19.0) 31(24.6)
Place for treatment a sick children
Community health center 98(84.5) 109(86.5)
Hospital 8(6.9) 3(2.4)
Traditional practitioner 3(2.6) 8(6.3)
Use own treatment 7(6.0) 6(4.8)
4. PENDIDIKAN, KESETARAAN GENDER & PERAN
INSTITUSI
 CERITA DARI PESISIR KOTA KENDARI
• Marsenita, sekitar 29 tahun, lulusan SMA
dan bekerja sebagai penjahit. Dia tinggal
bersama suami dan 2 anaknya di sebuah
rumah kontrakan yang memiliki 2 kamar.
Lingkungan rumah baik di dalam maupun
di luar tidak begitu bersih. Anaknya yang
paling kecil berusia 14 bulan. Dia
memberi tahu kami tentang riwayat
pemberian makan anaknya dengan jelas.
Ia menyusui anaknya secara eksklusif
sampai 4 bulan. Pada usia 4 bulan,
anaknya diberi pisang dua kali sehari.
Pada usia 5 bulan hingga 7 bulan,
anaknya diberi makan bubur instan
sementara ASI masih terus diberikan.
Pada usia 8 bulan, anaknya diberi makan
2 kali sehari dengan 'bubur' yang
dicampur dengan sayuran seperti labu
atau wortel.
Effendy DS et. al., 2018: feeding practice of child under 2 yr in
coastal area of SE Sulawesi: a qualitative study, 2018
 CERITA DARI PESISIR KOTA KENDARI
• Saat ini, pada usia 14 bulan, anak masih
mendapatkan bubur lembut yang
dicampur dengan sayuran. Protein
hewani jarang diberikan. Pada siang hari
dia memberikan biskuit sebagai camilan
kepada anaknya, dan anak itu akan
makan 2 hingga 3 potong. Saat kami
temui anaknya dalam kondisi demam,
dan mengalami diare. itu bukanlah hal
yang mengkhawatirkan karena dianggap
sebagai hal yang biasa ketika anak mau
tumbuh gigi. Berat badan bulan ini sama
dengan berat badan pada bulan
sebelumnya berdasarkan catatan
posyandu.
• Makanan untuk anak-anak tergantung
pada makanan keluarga. Namun,
makanan terbaik yang tersedia di rumah,
diberikan ke ayah.
Effendy DS et. al., 2018: feeding practice of child under 2 yr in
coastal area of SE Sulawesi: a qualitative study, 2018
PENGETAHUAN SIKAP PRAKTEK DAN PERSEPSI
MALNUTRISI

• Knowledge
• Attitude FOOD INSECURITY,
PERAWATAN ANAK YG
• Practice TDK ADEKUAT,
• Perceptions PRAKTEK KESEHATAN
YG TDK ADEKUAT

PENYEBAB DASAR SULIT/BUTUH

WAKTU UNTUK BERUBAH
Effendy DS et. al., 2018: feeding practice of child
under 2 yr in coastal area of SE Sulawesi: a
qualitative study, 2018
Culturally, the best food available at
home, such as fish or chicken meat,
is provided for the father as the
main family financial supporter
• sikap sosial terhadap anak dan perempuan---
menjadikan anak dan wanita ad klp rentan
• “I took the liquid part of the fish
soup and blended it with ‘bubur’.
The liquid part is better than the
meat part of the fish. The meat part
will be eaten by his father” (mother
of an 8-monthpold child, BN region).
• “Big fish only for father, the rest for
others” (mother of a 14-month-old
child, BN region).
• “There is a belief here that fish is not
good for a young child. It will cause
a child’s sweat to become fishy.
Therefore, child’s food is usually
only mixed with vegetables” (cadre,
NB region).
• Masalah malnutrisi kompleks—perilaku
makan sulit untuk diubah ketika
determinanya adalah sikap dan
kebiasaan yg berasal dari budaya

Nutrition officers and cadres did not
understand the latest issues of child
complementary feeding practices to
provide at least 4 groups of food
daily in the complementary feeding
period
KURANGNYA KAPASITAS INSTITUSI UNTUK MENYELESAIKAN MASALAH SECARA SERIUS
Effendy DS et. al., 2018: feeding practice of child under 2 yr
in coastal area of SE Sulawesi: a qualitative study, 2018
• “On the day of Posyandu, our duty is
preparing the equipment needed for
weighing, preparing a registration
book, and recording the weighing
results. Besides, we provides ‘bubur
kacang ijo’ for the children. That's it,
I never did counseling.” (cadre of NB
region).
• “We were given refreshing or
training. But there was no material
about child feeding. If there is a
child with poor nutrition coming to
Posyandu, the midwife will give the
mother suggestions.” (cadre of BN
region).
 lack of maternal nutrition
knowledge, beliefs and
perceptions was the barrier
to achieving optimal feeding
practices
5. LINGKUNGAN YANG TDK SEHAT & KURANGNYA
SUMBER DAYA
KONDISI PERUMAHAN YANG PADAT DAN LUAS BANGUNAN
YG TDK SESUAI DGN JUMLAH PENGHUNI
SANITASI LINGKUNGAN
PENYEDIAAN AIR BERSIH
KONDISI GEOGRAFIS: SULIT MEMANFAATKAN
LAHAN
INTERVENSI DAN PERAN STAKEHOLDERS DALAM
PENYELESAIAN STUNTING SEBAGAI MASALAH
KESEHATAN MASYARAKAT
INTERVENSI DAN PERAN STAKEHOLDERS

• INTERVENSI MULTISEKTOR
• INTERVENSI GIZI SPESIFIK DAN SENSITIVE
• PERAN PEMERINTAH
CONTOH INTERVENSI DI WILAYAH PESISIR
SULTRA
Nutrition Education

“Smart Mother for Healthy

Children Movement”

Nutrition classes
Monthly cadre’s home
visiting
Nutrition Education
Nutrition Class & Cooking Practice

• Time: June 2018

• Venue: district venue, health center
venue
• 4 sessions nutrition classes, 2.5 to 3
hours twice / week
• Person in charge: principal
researcher, 4 nutritionists, and 1
medical doctor
• Topic for teaching from Infant and
Child Feeding Counseling Package
developed by UNICEF for Indonesia
and the messages modified base on
Nutrition Education
Nutrition Class & Cooking Practice

• Practiced to make
meal consists of 4
groups of food
Ex of food: rice + tuna fish +
vegetable (pumpkin,long beans) + fruits

• Spinach cake
Nutrition Education
Nutrition Class & Cooking Practice

• Stick tempe
• anchovy powder,
anchovy biscuits,
and sea urchin
cookies
Nutrition Education
Cadre’s home visiting

• Time: once / month, Juli to October

2018
• Person in charge: 11 cadres ( 1 cadre
for intervention village:10-15
mothers)
• Cadre’s task: reinforce messages,
collecting the food record form
and health report form
SUMBER
SUPPLEMENTARY
The Role of Hormone and
Nutrient in Linear growth
• Linear growth are controlled mainly
in the level of long bone growth

• Key regulator :
Genetic determination
Dietary type 2 nutrients
Hormonal Regulation of linear growth

• Key regulator : Growth

Hormone (GH)

• Other hormones : Thyroid

estrogen& testosterone,
Cortisol
 The Role of Protein
•Epiphyseal cartilage width, protein and
proteoglycan synthesis inhibited within 3 days of
protein deficiency

•Actual length growth inhibition observed after 3

days of protein deficiency

Protein •Dietary protein can maintain bone growth in

conditions of modest energy deficiency with
reduces bodyweight

•Insulin, T3 and IGF-1 all fall with protein

deficiency
The Role of Zinc

• Stimulates bone
synthesis & bone
formation

• Zink augments
anabolic effect of
IGF-1 on osteoblast

Brandao Neto et all, 1995, MacDonald, 2000, Salgueiro et all, 2002

Other micronutrients :
I, Fe, Mn, Ca, Vitamin
A, Vitamin D

involved but specific

deficiency signs & symptoms
would be observed