Lessons learnt from TTS: Different Approaches in dealing with stunting preventions

Elviyanti Martini

1) Monitoring, analysis, mapping and response to food and nutrition insecurity;

Country Programme Action Plan 2012-2015

WFP Supports GoIin 3 areas

2) Emergency preparedness and response and building resilience among vulnerable population groups;

3) Reducing under-nutrition below critical levels (Nutrition, HIV, School Meals and FFA).

Reducing undernutrition is a key priority for both WFP and the GoI

Stagnating/Increasing stunting

36.8% (2007) to 37.2% (2013)=9 million children

Great disparities at subnational level with highest prevalence in NTT (51.7%) and NTB (45.3%)

Resilient wasting

13.9% U5 (2013) = 3.3 million children

Emerging overweight

11.9% U5, 32.9% of women, 19,7% of men

Deteriorating maternal health

24.2% of pregnant women have CED and 37.1% anemia

One of the highest maternal mortality rates in Southeast Asia: 359 per 100,000 births

WFP supports GoI through two-tiered strategy

Support GoI in its efforts to fight child and maternal undernutrition

especially by increasing access to the right food at the right time during the first 1,000 days

WFP Nutrition Strategy

I) Policy advocacy and

capacity development

II) Prototypes of nutrition-specific and

nutrition-sensitive interventions

Focus on supporting policies and enabling their implementation through appropriate tools

I) Policy advocacy and capacity development

Tools for evidence-based decisions

and policies

Cost of Diet

Food Security and Vulnerability Atlases

Food Security Monitoring System

Food and Nutrition Surveillance System

Support to policy design and

implementation

Scaling Up Nutrition (SUN)

Food and Nutrition Action Plan

(National, Provincial and District levels)

Nutrition sector review, RPJMN 2015-

2019

National standards for supplementary and

complementary feeding

Knowledge building and

transfer

Technical workshops

Participation to exchange forums such

as nutrition think tanks, MIYCN Working

Group, GKIA

EXAMPLE: the Cost of the Diet tool (CoD)Linking economic access to poor nutritional outcomes: Findings of the CoD In several districts, affordability of nutritious diet is problematic

Baldi G. et al.,Cost of the Diet (CoD) tool: First results from Indonesia and applications for policy discussion on food and nutrition

security. (2013).

Hubungan antara kemampuan membeli makanan bergizi dan kekurangan gizi

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10

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20 30 40 50 60

Perc

ent

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lds

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can

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ford

LA

CO

N d

iet

Prevalence of stunting

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10

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10 20 30 40 50Pe

rcen

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at c

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affo

rd L

AC

ON

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tPrevalence of underweight

Commitment to stunting

• Prevalence of stunting in children aged less than five years by wealth quintile in 2007, 2010 and 2013 (RISKESDAS) shows that stunting rates have increased or stagnated even in the richest income quintiles

• Since the richer income quintiles do hypothetically have the purchasing power to procure adequate nutritious products for the “first 1,000 days” the market should be able to offer a solution

As stunting is not just a problem of the poor, the market can be a key part of the solution

WFP response focuses on areas with the most pressing food security and nutrition needs

DRAFT

SO NTTSchool Meal 9480MCN 15000FFA 21000

SO PAPUA School Meal 1750

SO NTBFFA 17000

Nutrition prototypes focus on areas with high malnutrition prevalence: Nusa Tenggara Timur

Prevalence of food insecurity

TTS has been a priority 1 area since 2005 according to FSVA

2005: Indonesia

2009: Indonesia

2010: NTT

2010: TTS

Source: WFP, FSVA from respective years

36.8 36.6 37.2

46.8

58.44

51.73

57

80.65

70.43

0

10

20

30

40

50

60

70

80

90

2007 2010 2013

Perc

en

tag

e o

f p

op

ula

tio

n o

f U

5

Trend kekurangan gizi

Prevalence of stunting Prevalence of wasting

Stunting di TTS lebih tinngi dari rata-rata Indonesia dan NTT

Source: Riskesdas from respective years

U5: Children under five years of age

13.7

12.1

20

13.3

15.4415.3

11.37

14

0

5

10

15

20

25

2007 2010 2013

Perc

en

tag

e o

f p

op

ula

tio

n o

f U

5

WFP’s prototypes to support GOI to respond both immediate and underlying causes of undernutrition

Intervensi

Children who are undernourished in the first 2 years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition

Interventions after two years of age are too late as much of the early damage is irreversible and intervention would be more expensive

WFP has set a standard for minimum nutritional intake during these periods, distributes adequate supplements and constantly monitors the impact

WFP fokus pada “window of opportunity” dalam 1,000 HPK

The prototypes focus on the first 1,000 days but also address nutrition throughout the life-cycle

First 1,000 days

Improvement of existing supplementary food products w/ local private sector

Local development of LNS

Provision of MP-ASI and LNS through pilot in TTS

Evidence-building: effectiveness, evaluations, Lesson Learnt on various delivery mechanisms

Support local health sector on growth monitoring and BCC for health and nutrition

Voucher pilot to increase access to specialized food during 1,000 days

Life-cycle

Integrated local school meals w/ MNP and BCC

Support to local farmers

Food for Assets to improve resilience

Pemberian ASI dan MP-ASI yang Baik Sangat Penting untuk Pencegahan Stunting. Vitamin dan Mineral harus mencukupi

Contoh:

Zat besi dan Yodium untuk perkembangan kognitif/kecerdasan

Zinc: untuk pertumbuhan dan fungsi kekebalan tubuh

Vitamin A: untuk perkembangan retina dan system kekebalan tubuh dan kelangsungan hidup

Photo from UNICEF Azerbaijan

Kapan “Jendela Emas” untuk memperbaiki PMBA?

Victora C.G. et al, 2010

10 prinsip pedoman pemberian MPASI untuk anak yang diberi ASI

1. Exclusive breastfeeding (EBF) selama 6 bulan pertama kehidupan dan pengenalan MPASI pada usia 6 bulan

2. Tetap memberikan ASI sampai anak berusia dua tahun atau lebih

3. Pemberian makan yang responsif

4. Penyiapan dan penyimpanan MPASI yang aman

5. Jumlah MPASI yang cukup

18

6. Konsistensi makanan yang tepat

7. Jumlah frekwensi makan yang cukup dan kaya akan energi

8. Mengandung zat gizi yang cukup (zat gizi makro dan gizi mikro)

9. Penggunaan supplemen vitamin dan mineral seperti Taburia danMPASI yang berfortifikasi untuk bayi dan ibu

10. Meningkatkan pemberian makanan ketika anak sakit atausesudah sembuh dari sakit (e.g. diarrhea) 19

10 prinsip pedoman pemberian MPASI untuk anak yang diberi ASI

Berapa energy yang dibutuhkan dariMPASI?

0 200 400 600 800 1000

12-23months

9-11months

6-8months

FromBreastmilk

FromCF

kcalUkuran lambung bayi terbatas, pada usia 6 bulan ~100mL dan pada usia 24 bulan ~200mL

Kandungan Zat Gizi yang CukupSetelah 6 bln, ASI memberikan <50% kebutuhan untuk beberapa zat gizi

Nutrient % of requirement for 6-8 month olds that must be met by complementary foods

Iron 98%

Vitamin D 93%

Zinc 80%

Vitamin B6 79%

Niacin 75%

Thiamine 53%

Calcium 53%

Apa yang bisa kita lakukan…

• Untuk meningkatkan kepadatan energi?

– Kurangi air, buat bubur lebih kental

– Tambahkan minyak pada bubur

• Untuk meningkatkan kepadatan kandungan gizi (baik gizi makro dan mikro)?

– Diversifikasi – berikan makanan yang bervariasi

– Makanan padat gizi – makanan sumber hewani

Let’s try …

MPASI “Ideal” :

20g nasi15g kacang-kacangan15g sayuran hijau22g (setengah) telur ayam20g ikan10g minyak

Sumber: Vitta, Dewey, 2012

Persentasi kebutuhan zat besi dan zinc yang dipenuhi oleh MPASI yang tidak berfortifikasi untuk

anak usia 6-8 bulan

Persentasi kebutuhanyg dipenuhi dari MPASI

MPASI“Realistik” 20g nasi15g kacang-kacangan15g sayuran hijau22g (setengah) telurayam20g ikan10g minyak

Zat Besi yang Bioavailable (zat besiyang diserap) dari MPASI dalam porsi

100gr

0 1 2 3 4 5

Beef

Pork

Chicken

Egg(chicken)

Barley

Fish

Legumes,nuts

Greenleafy

Ironfor fied

AbsorbedIron

TotalIron

mg

Current situation of practices: Introduction of Complementary Foods and

Minimum Acceptable Diet

Source: DHS of listed countries, 2002-2008

Defisit Zat gizi anak-anak di amanuban barat dan Kie,TTS

6-11 bulan 12-23 bulan

Energi 6-21% 22-38%

Protein 13-29% 15-34%

Zat Besi 67-81% 60-66%

Sumber: ACHEAF, 2012

Intervensi program gizi ibu dan anak

• Recipients are spread across 440 posyandu

• Children receive MP-ASI (3 sachets per day = 1.8 kg/month/child)

• 30 posyandu have been selected for monitoring and evaluation of anthropometric

data (weight, height and age of children, MUAC of PLW)

• Training has been provided to the posyandu to conduct the measurements

• Poltekkes University oversees the measurements

• Behavior Change Communication is also implemented in all 400 posyandu

2005-2011 2012 20142013

Local Food Based School Meals (LFBSM)

• Target: 13,000 children 7-12years

• Product: Maize, mung beans, Vitas

• Method: Cooking in 74 schools

2012-ongoing

Mother and Child Nutrition Programme (MCN)

• Target: 11.500 children 6-24months, 6500 PLW

• Product: MP-ASI and LNS, fortified biscuits,

• Method: 440 posyandu

WFP Target areas

• MP-ASI Interventions in 17 out of 32 subdistricts

• 440 Posyandu out of 712 are reached by the Mother and Child Nutrition Programme (MCHN)

• 30 Posyandu with tracking of anthropometric data since Q4 2012, selected to represent the entire activity area (PPS)

Activity area and measurement is spread across TTS

WFP MCHN area

Posyandu participating in anthropometric measurement

Source: WFP

Prevalensi stunting (Pendek)

Prevalence of stunting Prevalensi stunting pada baduta berkisar 54.5%

70.43%

2013 TTS

average

for U5

53%

Median of

measure-

ments

Source: Riskesdas from respective years; WFP anthropometric measurements

U2/U5: Children under two/five years of age

25.029.6

22.327.3 25.9

20.825.9 26.2

26.9

29.7

27.5

32.028.6

23.4

24.530.3

51.8

59.3

49.8

59.3

54.5

44.2

50.4

56.5

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 Q1 '14 Q2 '14 Q3 '14

Per

cen

tage

of

stu

nti

ng

in U

2

Severe stunting

Moderate stunting

Prevalensi wasting (kurus)

Prevalence of wasting

Prevalensi wasting (kurus) sudah menurun

Prevalensi meningkat pada masa paceklik

14.0%

2013 TTS

average

for U5

Source: Riskesdas from respective years; WFP anthropometric measurements

U2/U5: Children under two/five years of age

3.73.0

1.9 1.7

3.23.9

22.9

7.0

4.85.7 6.2

5.3

8.6

5.9

5.8

10.7

7.7 7.67.9

8.5

12.5

7.9

8.7

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 Q1 '14 Q2 '14 Q3 '14

Per

cen

tage

of

was

tin

g in

U2

Severe wasting

Moderate wasting

Intervensi lainnya

• Pengembangan home gardening, Embung dan irigasimelalui program Food for Asset

• FNAP at national, provincial and district levels;NTT, NTB, Papua

Kesimpulan

• Prevalensi of stunting dan wasting lebih rendah pada daerah dimana ada programme WFP dibanding data TTS secara keseluruhan dari Riskesdas 2013,

• Program perlu dilakukan selama satu siklus penuh selama 3 tahun untuk dapat melihat dampaknya pada stunting, Penurunan prevalensi wasting menunjukan dampak positive

• MPASI berfortifikasi bermanfaat untuk menutup defisit zat gizi, disertai usaha perbaikan PMBA yang optimal dan perbaikan lingkungan dan peningkatan pelayanan kesehatan. Apabila tidak ada defisit energi, pemberian makanan lokal dengan penambahan taburia dapat dianjurkan

• Program Gizi spesifik dan gizi sensitive harus dilakukan bersamaan

1

2

3

4

Thank you