Sage Journals: Discover world-class research

Abstract

Background:

Stunting is a condition of toddlers who experience growth failure due to chronic nutrient deficiencies that must be addressed immediately, if children lack nutrients continuously, it can affect their nutritional status and will cause children to be shorter than their age. The purpose of this study was to determine the differences in macronutrient intake in stunted and non-stunted toddlers in Jember, Indonesia.

Design and methods:

Type of analytical observational research with case control design, sampling technique using simple random sampling. The number of subjects needed in each group is 66 stunting toddlers and 66 non-stunting toddlers with total subjects used are 132 toddlers.

Results:

There are differences in macronutrient intake: energy, protein, fat, and carbohydrates between stunted and non-stunted toddlers with a higher average value of food intake per day for non-stunted toddlers than for stunted toddlers.

Conclusions:

There are differences in macronutrient intake between stunted and non-stunted toddlers in Jember, Indonesia with a p-value = 0.000 < 0.05.

Keywords

Intake stunting macronutrients

Introduction

Stunting is a condition of toddlers who experience growth failure due to chronic nutrient deficiencies so that children become shorter than their age.¹ Stunting can be seen through measuring height or length or calculating the z-score value, if it is less than −2 standard deviation then it can be declared stunted or short.² Stunting can have a negative impact on toddlers, which consists of short-term and long-term impacts.³ Short-term impacts; increased morbidity and mortality, suboptimal cognitive, motor, and verbal development in children, increased health costs. While the long-term impact; suboptimal posture as an adult (shorter than in general), increased risk of obesity and other diseases, decreased reproductive health, suboptimal learning capacity and performance during school, and suboptimal productivity and work capacity.⁴

The average prevalence of stunting in the Southeast Asia Region is 36.4%, while the World Health Organization gives a limit for stunting prevalence of <20%.⁵ East Java Province has 12 districts or cities that are the locus of stunting: Trenggalek, Malang, Kediri, Nganjuk, Probolinggo, Lamongan, Bangkalan, Sampang, Pamekasan, Sumenep, Bondowoso, and Jember.⁶ The prevalence of stunting in Indonesia in 2019 was 27.7% and in East Java in 2019 was 26.9%.⁷ Jember Regency has a stunting prevalence above the national average of 37.94%. In 2020, there were 10 subdistricts that became priority locus villages: Gumukmas, Jelbuk, Kaliwates, Kencong, Mayang, Puger, Silo, Sumberjambe, Sumbersari, and Tanggul.⁶ The prevalence of stunting in Jember Regency is highest in Jelbuk Subdistrict, with 659 children or equivalent to 31.84% with an age range of 0–5 years.⁸ From the data obtained from the Jelbuk Health Center, Panduman village has the highest number of stunted toddlers, 170 toddlers.⁸

Stunting can occur due to maternal nutrition during pregnancy, family socioeconomic conditions, infant morbidity, and lack of nutritional intake in infants.⁹ Macronutrients are the main food sources that provide the most energy for the human body.¹⁰ Macronutrient deficiencies affect the growth and development of children under 5 years of age. If toddlers experience a deficiency in energy intake, it will have an impact on the function and structure of brain development, and will also have an impact on inhibiting cognitive development and growth.¹¹ Deficiency in protein intake will result in inhibition of children’s height growth.¹² Fat intake is also very necessary in the growth of toddlers, if toddlers experience a deficiency in fat intake, it affects the nutritional status of toddlers because it contains essential fatty acids that play a role in regulating the health of toddlers.¹³ In addition, deficiency in carbohydrate intake also has an impact on child growth and brain development, as carbohydrates serve as the main supply of energy.¹⁴ Therefore, macronutrient intake in toddlers, especially in stunted toddlers is needed to support growth and development in children in order to minimize the occurrence of health problems. This study aimed to analyze differences in macronutrient intake among stunted and non-stunted toddlers in Jember, Indonesia.

Design and methods

Study area

This study was conducted in Panduman Village, Jelbuk Subdistrict, Jember Regency (Figure 1). Panduman Village is one of the villages with the highest prevalence of stunting in Jelbuk Subdistrict, where Jelbuk Subdistrict has the highest prevalence in Jember Regency. Panduman Village is located in a highland area that has fertile soil conditions that are used as agricultural and plantation land. Panduman Village has several hamlets, namely Sumber Tengah, Krajan I, Krajan II, Siwan Lor, Lamparan, Siwan Kidul, Bacem, and Sumber Candik. In addition, Panduman Village has 9 Posyandu. The road to Panduman Village in the lower area is quite easy to reach, but the road to Panduman Village in the upper area is quite difficult to reach because the road is uphill and rocky.

Figure 1.

Geographic location of the research area.

Study design and data collection

This study used analytical observational research with a case control design conducted on March 17–28, 2022. The population in this study were 511 toddlers in Panduman Village. Taking subjects in this study using simple random sampling technique based on predetermined inclusion and exclusion criteria. This study used a subject of 66 stunted and 66 non-stunted toddlers. The instruments used in this study were informed consent, stationery, Semi-Quantitative Food Frequency Questionnaire (SQ-FFQ) questionnaire form, food picture, Statistical Product and Service Solution (SPSS) and Nutrisurvey 2007 as data processing software.

Statistical analysis

First, descriptive analysis in terms of frequency tabulation, numerical summary, and basic statistical inference of basic statistics in the form of curves. Curves were used to compare macronutrient intake: energy, protein, fat and carbohydrates in stunted and non-stunted toddlers. Independent t-test analysis was conducted to determine whether there were differences in the intake of macronutrients: energy, protein, fat, and carbohydrates in stunted and non-stunted toddlers presented in tabular form.

Ethical consideration

Ethical approval was done for this study which was conducted at Politeknik Negeri Jember with number 199/PL17/PG/2022. Permission to use the data was granted by the Jember District Health Office for Jelbuk Health Center.

Results

Demographic characteristics in this study include mother’s education, mother’s occupation, family income, and mother’s disease history. Related demographic characteristics can be seen based on Table 1.

Table 1.

Demographic characteristics of subjects study.

Demographic characteristics	n	Stunted percentage (%)	n	Non-stunted percentage (%)
Mother’s education
No school	3	5	-	-
Elementary school	47	71	42	63
Middle school	16	24	14	21
High school	-	-	7	11
University first stage	-	-	3	5
Mother’s occupation
Unemployment	55	83	60	91
Labor	5	8	-	-
Private employee	6	9	4	6
Teacher	-	-	2	3
Income
Rp 500,000	8	12	8	12
Rp 1,000,000	42	63	41	61
Rp 1,500,000	11	17	7	11
Rp 2,000,000	5	8	7	11
Rp 3,000,000	-	-	3	5

The results of research related to the demographic characteristics of families of stunted and non-stunted toddlers related to education show that maternal education is dominated by elementary school graduates. The education of mothers of stunted and non-stunted toddlers is different, the lowest education for mothers of non-stunted toddlers is elementary school and there are some mothers who have reached college education. While the mothers of stunting toddlers there are some mothers who have never taken education or do not attend school and the highest education taken is junior high school.

The average macronutrient intake (energy, protein, fat, and carbohydrate) of stunted and non-stunted toddlers in Jember, Indonesia can be seen in Figure 2.

Figure 2.

Average of macronutrient intake: (a) energy, (b) protein, (c) fat, and (d) carbohydrate.

The average intake of macronutrients including energy, protein, fat, and carbohydrates in stunted toddlers is lower than non-stunted toddlers. However, the average amount of protein and fat intake in stunted toddlers exceeds the needs recommended by the nutritional adequacy rate, while the average amount of energy and carbohydrate intake in stunted toddlers has met the needs recommended by the nutritional adequacy rate. The average intakes of energy, protein and fat in non-stunted toddlers were more than the recommended nutritional requirements, while the average intake of carbohydrates was sufficient to meet the recommended nutritional requirements. This may be due to different food consumption between stunted and non-stunted toddlers. Based on observations during the study, mothers of toddlers pay less attention to the consumption of food given to children. Another possible factor is the lower consumption of staple foods compared to the consumption of snacks such as meatballs, and sausages. In addition, most toddlers consume formula milk and soy milk so that their nutritional intake exceeds the recommended needs.

The nutrition of stunted and non-stunted toddlers in each of the 66 toddlers which means a total of 132 toddlers can be seen in Table 2. The results of the independent t-test of macronutrient intake including energy, protein, fat, and carbohydrates obtained a p value = 0.000 (<0.05) which means there are differences in macronutrient intake including energy, protein, fat, and carbohydrates between stunted and non-stunted toddlers.

Table 2.

Independent t-test of macronutrients in stunted and non-stunted toddlers.

Macronutrient	Stunted		Non-stunted		Min	Max	SD	p
Macronutrient	n	Mean	n	Mean	Min	Max	SD	p
Energy	66	1304.4	66	1767.9	129.9	3843	667.6	0.000
Protein	66	53.47	66	72.56	1.1	186.8	34.30	0.001
Fat	66	50.86	66	67.62	2.4	116.5	27.21	0.000
Carbohydrates	66	136.94	66	184.88	14.4	412	65.77	0.000

Discussion

A mother’s education will affect the occurrence of stunting in children, this is because mothers who have high knowledge will pay attention to the child’s diet so that the child’s nutritional intake will be fulfilled.¹⁵ Most mothers of toddlers with stunted and non-stunted conditions do not work. There is no significant relationship between working mothers and the incidence of stunted, but working mothers in toddlers with stunted are higher than mothers of toddlers with non-stunted.¹⁶ Diversity of education of mothers as primary caregivers may affect child feeding.¹⁷ Low family income will have a 4x greater risk of affecting undernutrition status than sufficient family income.¹⁸ Education, occupation, and family income are indicators that can affect nutritional intake in the family. If a family’s economy is classified as good, the nutritional intake needs of the family will be fulfilled.¹⁹

Macronutrient intake in stunted and non-stunted toddlers showed that there were significant differences in each macronutrient between the two. Other similar studies have found an association between energy, protein, fat and carbohydrate intake and child length, suggesting that macronutrient intake is associated with stunting.^20,21 According to Scaglioni et al.²² toddlers who experience excess nutrients can be caused by toddler mothers paying less attention to the balance of nutrients in the toddler’s diet, for example, such as toddlers consuming milk more often so that children will be full faster.²³ This is also in line with the research of Ernalia et al.²⁴ that there are differences in energy and protein intake in stunted and non-stunted toddlers. Other studies explain that fat intake has a relationship with stunted.²⁵ Differences in protein and carbohydrate intake in stunted and non-stunted toddlers, but in energy and fat intake there is no difference between stunted and non-stunted toddlers.²⁶ The average intake of macronutrients (energy, protein, fat, and carbohydrates) has an intake of more than the recommended needs. This is because the food consumed by stunted and non-stunted toddlers every day is high in calories and protein. Toddlers should consume other foods that are high in carbohydrates to fulfill their nutrient deficiencies.

Conclusion

The average intake of protein, and fat in stunted toddlers is more than the recommended needs while the average intake of energy and carbohydrates meets the recommended needs. Whereas in non-stunted toddlers the average intake of energy, protein, and fat exceeds the recommended needs and carbohydrate intake meets the recommended needs. Analysis of the relationship between energy, protein, fat, and carbohydrate intake has a significant difference in stunted and non-stunted toddlers with the average intake of non- stunted toddlers higher than stunted toddlers.

Footnotes

Acknowledgements

The authors appreciate Politeknik Negeri Jember, Universitas Nahdlatul Ulama Surabaya and Hungarian University of Agriculture and Life Science for the support and facilitation during this research work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

ORCID iD

Edza Aria Wikurendra

References

Branca

Ferrari

. Impact of micronutrient deficiencies on growth: the stunting syndrome. Ann Nutr Metab 2002; 46(Suppl. 1): 8–17.

Kahssay

Woldu

Gebre

, et al. Determinants of stunting among children aged 6 to 59 months in pastoral community, Afar region, North East Ethiopia: unmatched case control study. BMC Nutr 2020; 6(1): 9.

De Sanctis

Soliman

Alaaraj

, et al. Early and long-term consequences of nutritional stunting: from childhood to adulthood. Acta Biomed 2021; 92(1): e2021168.

Saputri

Tumangger

. Stunting management policy in Indonesia. J Polit Issues 2019; 1: 1–9.

World Health Organization. World health statistics 2022: Monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization, 2022. https://apps.who.int/iris/bitstream/handle/10665/356584/9789240051140-eng.pdf (accessed 23 August 2023).

Pusat Data dan Informasi. Situasi balita pendek (Stunting) di Indonesia. Jakarta: Pusat Data dan Informasi, 2018. https://www.kemkes.go.id/article/view/16090700002/situasi-balita-pendek-di-indonesia.html (accessed 23 August 2023).

Izwardy

. Studi Status Gizi Balita Terintegrasi Susenas 2019. Jakarta, 2020. https://www.academia.edu/download/62187267/FINAL_PAPARAN_PERSI_22_FEB_2019_Ir._Doddy20200224-42067-1yu8u1e.pdf (accessed 23 August 2023).

Dinas Kesehatan Kabupaten Jember. Profil Kesehatan Kabupaten Jember Tahun 2020. Jember, 2021. https://ppid.jemberkab.go.id/storage/dip-dikecualikan/7WhJreTqH3UScJ9DCAqjh8TfsTLgtyfhPKy4Le5U.pdf (accessed 23 August 2023).

Ali

. Current status of malnutrition and stunting in Pakistani children: what needs to be done? J Am Coll Nutr 2021; 40(2): 180–192.

10.

Prentice

. Macronutrients as sources of food energy. Public Health Nutr 2005; 8(7a): 932–939.

11.

Bryan

Osendarp

Hughes

, et al. Nutrients for cognitive development in school-aged children. Nutr Rev Internet 2004; 62(8): 295–306.

12.

Millward

. Nutrition, infection and stunting: the roles of deficiencies of individual nutrients and foods, and of inflammation, as determinants of reduced linear growth of children. Nutr Res Rev 2017; 30(1): 50–72.

13.

Savarino

Corsello

. Macronutrient balance and micronutrient amounts through growth and development. Ital J Pediatr 2021; 47(1): 109.

14.

Huff

Denne

Hay

Jr . Energy requirements and carbohydrates in preterm infants. In: World Review of Nutrition and Dietetics. 2021, pp.60–74. https://www.karger.com/DOI/10.1159/000514736

15.

Maharani

Purwati

Permatasari

TAE

. Screening for malnutrition and the effect of education using the STRONGkids application on increasing mother’s knowledge and children’s eating behavior. Int J Soc Sci World 2020; 2: 144–152.

16.

Win

Shafique

Mizan

, et al. Association between mother’s work status and child stunting in urban slums: a cross-sectional assessment of 346 child-mother dyads in Dhaka, Bangladesh (2020). Arch Public Health 2022; 80(1): 192.

17.

Saaka

Wemah

Kizito

, et al. Effect of nutrition behaviour change communication delivered through radio on mothers’ nutritional knowledge, child feeding practices and growth. J Nutr Sci 2021; 10: e44.

18.

Galgamuwa

Iddawela

Dharmaratne

, et al. Nutritional status and correlated socio-economic factors among preschool and school children in plantation communities, Sri Lanka. BMC Public Health 2017; 17(1): 377.

19.

Alkerwi

Vernier

Sauvageot

, et al. Demographic and socioeconomic disparity in nutrition: application of a novel correlated component regression approach. BMJ Open 2015; 5(5): e006814.

20.

Nguyen

Santos

Braun

KVE

, et al. Carbohydrate intake in early childhood and body composition and metabolic health: results from the generation R study. Nutrients 2020; 12(7): 1940.

21.

Beyerlein

Uusitalo

Virtanen

, et al. Intake of energy and protein is associated with overweight risk at age 5.5 years: results from the prospective TEDDY study. Obesity 2017; 25(8): 1435–1441.

22.

Scaglioni

De Cosmi

Ciappolino

, et al. Factors influencing children’s eating behaviours. Nutrients 2018; 10(6): 706.

23.

Savage

Fisher

Birch

. Parental influence on eating behavior: conception to adolescence. J Law Med Ethics 2007; 35(1): 22–34.

24.

Ernalia

Dwi Utari

L, S

, Different intakes of energy and protein in stunted and non-stunted elementary school children in Indonesia. KnE Life Sci 2018; 4: 556.

25.

Basri

Hadju

Zulkifli

, et al. Dietary diversity, dietary patterns and dietary intake are associated with stunted children in Jeneponto District, Indonesia. Gac Sanit 2021; 35: S483–S486.

26.

Fikawati

Syafiq

Ririyanti

, et al. Energy and protein intakes are associated with stunting among preschool children in Central Jakarta, Indonesia: a case-control study. Malays J Nutr 2021; 27(1): 081–091.

Macronutrient intake in stunted and non-stunted toddlers in Jember,Indonesia