Navigating Food Systems Towards National Nutrition Programs in Catalyzing Stunting Reduction in Indonesia

Child stunting reduction is the first of six goals in the Global Nutrition Targets for 2025 and a key indicator in the second Sustainable Development Goal of Zero Hunger. According to the National Nutritional Status Survey (SSGI - Survei Status Gizi Indonesia), the prevalence of stunting among children under five years in Indonesia has remained high over the past decade and, at the national level, is approximately 24,4 percent in 2021 and 21.6 percent in 2022. Furthermore, based on the Indonesian Health Survey (SKI – Survey Kesehatan Indonesia), the updated stunting prevalence 2023 was calculated at 21,5 percent, representing stagnation, and has not significantly decreased over the last three years. Consequently, the prevalence is still quite far from 14 percent, the National stunting reduction target by 2024, according to the National Medium-term Development Plan (RPJMN 2020 – 2024).

Nutritional problems among children under five can significantly affect a child's growth, development, and health status. These consequences include growth flattering, immune system impairment, and other health problems. If children do not require an adequate nutritional intake, they may experience growth flattering, resulting in an impaired body weight and higher than the age standard. Furthermore, adequate nutritional intake is essential for brain development during this period. For instance, if the children do not meet the essential nutrition requirements, such as iron and zinc, they may experience developmental delays that can affect their cognitive, emotional, and social development.

A critical window (sensitive period) represents a period during development responsive to intrinsic or extrinsic (environmental) factors. The intrauterine and early post-natal months are well known to be particularly critical for future health and brain development (Bergvall et al., 2006). Optimal maternal nutrition is essential for fetal and infant development and is closely linked with the maternal supply of essential nutrients, including vitamins and minerals. During the first two years after birth, nutritional requirements for rapid growth and development are very high. Thus, adverse factors have a more significant potential for causing growth retardation in early life. Frequent infections during the first two years of life also contribute to the high risk of becoming stunted during this period. Catch-up growth is possible in children older than two years, although stunting is often well-established by this age in many low-and middle-income countries.

The UNICEF's Conceptual Framework on the Determinants of Maternal and Child Nutrition acknowledged the increasing triple-burden of malnutrition – undernutrition (stunting, wasting, and underweight), micronutrient deficiencies, and overweight – and highlighted the diet position in tackling malnutrition. Sufficient foods, adequate dietary intake, and age-appropriate, high-dense nutrient food, including breastmilk and complementary foods for children with safe and palatable drinking water and household food security, are essential (UNICEF, 2021). However, Indonesia is still challenging to comply with these essential factors. Figure 1 shows that the most immediate determinants of stunting cases in Indonesia were correlated to foods, including complementary feeding-related factors. Moreover, there was 58.8 percent of children under five years experienced minimum dietary diversity intake.

One of the national programs being implemented is a sensitive and specific nutritional intervention in combating stunting. According to Escher et al. (2024), nutrition interventions, including nutrition-specific and nutrition-sensitive interventions, can directly or indirectly affect malnutrition. Nutrition-specific interventions target immediate causes of malnutrition, such as food intake or childcare practices, whereas nutrition-sensitive interventions focus on underlying factors, such as resource availability and accessibility.

The national program to alleviate stunting in Indonesia is comprehensive and ambitious, and, in many cases, it has adopted a food system approach. Nevertheless, the coverage of national nutrition programs remained low (Figure 2), implying that inequalities in coverage and quality gaps raise the question of whether Indonesia is spending enough on stunting-related interventions and using its resources efficiently (World Bank, 2020). What are the program's strengths and weaknesses when viewed through a food systems framework? Considering how well "the 2019 National Priority Program Planning: The Case of the Stunting Reduction Program" links food system drivers, activities, and outcomes. Furthermore, case studies are also discussed to identify opportunities and barriers to implementing the National Program at the local level.

Firstly, focus on food system activities, such as producing, processing, distributing, and consuming food. Local food is the essential point to secure the availability and accessibility of food. The key point is also on the food consumption. Diversification of local foods aims to accelerate the diverse dietary intake and is developed regarding the community resources and cultures (Gozali & Kusuma, 2019).

The P2L (Pekarangan Pangan Lestari) program is one of the priority programs in maintaining household food security in tackling stunting cases in Indonesia. The activity of the program is conducted to re-activate unproductive yards, idle land, and vacant land as market-oriented food production. Therefore, it may support household income (Badan Ketahanan Pangan, 2020). Renita et al., (2024) concluded that the P2L program has a positive impact on the community in terms of complying with the household commodity requirements at the medium level, particularly vegetables.

Additionally, globalization has brought about significant changes in livelihoods, including food trade policies that have increased the availability of imported and manufactured foods across regions and led to changes in food preferences. Socio-economic factors drive changes in food patterns. Economic drivers include urbanization, income, and market conditions, while social drivers include women's roles and prestige changes. Lastly, changes in the role of homemakers affect the quality of food provision. Mothers tend to provide unhealthy processed food (convenience food), which is easier to cook, quick to serve, cheap, and has more extended and stable storage quality.

Secondly, regarding food system outcomes, the program focuses heavily on public health outcomes, such as reducing malnutrition, improving nutrition education, providing more excellent infrastructure, and providing more integrated primary health services. Programs focus less on environmental outcomes: Greenhouse gas emissions, biodiversity loss, water scarcity, and food waste. These environmental constraints will positively impact food security if addressed in the medium to long term. The program also treats the economic outcomes of the food system only superficially. The food system is a significant opportunity for new businesses, contributing to millions of national livelihoods. A healthier, more sustainable food system is also suitable for the circular economy. Although the program states the need to synergize government and private sector food system activities, there needs to be more detail in the current strategy. More focus on food processing and distribution will deeply involve the private sector in the program.

From a food system perspective, current programs are powerful in consuming a healthy diet but less intense in involving the private sector in food processing and distribution. This is a significant opportunity for the new program to address. One way forward is to establish several pilot case study sites to analyze the implementation of the National Program at the local level, in line with the Early Childhood Development Strategy (Bappenas, 2018). The food system is a complex network of actors, processes, and resources, including production, processing, distribution, marketing, and consumption. It is essential to ensure that these systems provide safe, nutritious, and affordable food for all, especially vulnerable populations such as children under five. The food system can overcome the following problems of malnutrition:

• Increase availability and access to healthy and nutritious foods: This can be achieved by increasing the availability and affordability of nutrient-rich diets, such as fruits, vegetables, whole grains, and proteins. Local farming may catalyze this by reducing food waste, improving food processing and storage techniques, and improving food distribution systems. A systematic review that included 36 research found that household food insecurity is significantly correlated with stunting and underweight (Lye, et al., 2023). Furthermore, a retrospective cohort study also showed that the dimension of low food availability and quality was associated with stunting status (Koyratty et al., 2022).

• Providing micronutrient supplements: In cases where access to a variety of nutrient-rich diets is limited, food systems can provide micronutrient supplements to vulnerable populations, including children under five years, to ensure essential vitamins and minerals readiness for supporting development. This may be due to the food matrix, which captures the interactions between a food’s nutrient and non-nutrient components. So, maintaining a healthy, varied diet in whole, nutrient-dense diet is imperative for improving nutritional status.

• Ensuring food safety: Food systems can help prevent malnutrition by ensuring food is safe and free from contaminants that may lead to foodborne illness and disease. Recurrent infections may cause poor dietary intake, poor nutrient absorption and utilization, and nutrient loss, which also may impact attained growth (stunting).

• Promoting good feeding practices: Based on the pilot study, feeding practice may influence the sufficiency of nutrition provided to children, both in quality and quantity. The effectiveness of it is essential as it improves the nutritional status, which leads to lower stunting prevalence (Prendergast and Humphrey 2014). The improvement of good feeding practices can be aligned through education and awareness campaigns encouraging parents to provide their children with various healthy and nutritionally adequate foods. Previous studies provide support for interventions designed to increase maternal knowledge of nutrition and feeding practices to prevent stunting, including understanding how to modify the feeding methods, children’s hunger cues, encouraging children to eat, recognizing low appetite, creating a good feeding environment, etc. (Kim et al., 2016; Sahanggamu et al., 2017).

• Improving the nutritional quality of processed foods using fortification: Food fortification is the process of adding micronutrients to regularly consumed foods during processing to boost their nutritional value. Global and national experiences show that food fortification success is most likely when partnerships are formed not only between the public and private sectors, but also with parties or organizations that can contribute in the critical areas of advocacy, management, capacity building, implementation, and regulatory monitoring (Olson et al., 2021).

• Promoting appropriate nutritional education: Food systems can be essential in promoting appropriate nutritional education to parents (mothers). The programs of nutrition education may increase the knowledge of mothers (Muluye et al., 2020). Several studies have discovered that nutrition education influences maternal knowledge of stunting prevention (Ponum et al., 2020; Mistry et al., 2019; Setyawati and Kurniadi 2019). The program not only educates about clinical aspects of nutrition but also the importance of a balanced diet and how to prepare nutritious food for children.

References:

1. Badan Ketahanan Pangan. 2020. Petunjuk Teknis: Bantuan Pemerintah Kegiatan Pekarangan Pangan Lestari.

2. Bergvall N, Iliadou A, Johansson S, Tuvemo T, Cnattingius S. Risks for low intellectual performance related to being born small for gestational age are modifi ed by gestational age. Pediatrics. 2006; 117:460–467.

3. Escher, N. A., Andrade, G. C., Ghosh-Jerath, S., Millett, C., & Seferidi, P.. The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review. The Lancet. Global health 2024; 12(3), e419–e432.

4. Gozali G, Kusuma BJ. Identification of local food potential for diversification of food production in the city of Balikpapan. J Sos Hum Educator. 2019; 13 (3): 543-53.

5. Kementrian PPN/Bappenas. 2018. Percepatan Penurunan Stunting 2020-2024. Jakarta: Direktorat Kesehatan dan Gizi Masyarakat Kementerian PPN/Bappenas.

6. Kim SS, Rawat R, Mwangi EM, Tesfaye R, Abebe Y, Baker J, et al. Exposure due to large- scale social and behavior change communication interventions is associated with improvements in infant and young child feeding practices in Ethiopia. PLoS One 2016; 11(10): 1-18.

7. Koyratty N, Ntozini R, Mbuya MN, Jones AD, Schuster RC, Kordas K, Li CS, Tavengwa NV, Majo FD, Humphrey J, Smith LE. Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe. BMJ Nutrition, Prevention & Health 2022; 5(2): 332-343.

8. Lye CW, Sivasampu S, Mahmudiono T, Majid HA. A systematic review of the relationship between household food insecurity and childhood undernutrition. Journal of Public Health. 2023; 45: e677-e691.

9. Mistry SK, Hossain MB, Arora A. Maternal nutrition counselling is associated with reduced stunting prevalence and improved feeding practices in early childhood: a post-program comparison study. Nutrition Journal 2019; 18(1): 1-9.

10. Muluye SD, Lemma TB, Diddana TZ. Effects of nutrition education on improving knowledge and practice of complementary feeding of mothers with 6- to 23-month-old children in daycare centers in Hawassa town, southern Ethiopia: an institution-based randomized control trial, Journal of Nutrition and Metabolism 2020; 1-10.

11. Olson R, Gavin-Smith B, Ferraboschi C, Kraemer K. Food fortification: the adventages, disadvantages and lesson from Sight and Life programs. Nutrients 2021; 13(4): 1118.

12. Ponum K, Khan S, Hasan O, Mahmood MT, Abbas A, Iftikar M, Arshad R. Stunting diagnostic and awareness: impact assessment study of sociodemographic factors of stunting among school going children of Pakistan. BMC Pediatrics 2020; 20(1): 232.

13. Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Pediatr Int Child Health 2014; 34: 250-65.

14. Renita R, Helmyati S, Purwaningrum DN, Sitorus NL, Dilantika C. Contribution of the sustainable food yard program (P2L) to accelerating the stunting reduction in Sleman Regency during Covid-19 pandemic. Amerta Nutrition. 7(3SP): 30-40.

15. Sahanggamu PD, Purnomosari L, Dillon D. Information exposure and growth monitoring favour child nutrition in rural Indonesia. Asia Pac J Clin Nutr. 2017; 26(2): 313.

16. Setyawati VAV, Kurniadi AI. Improving mother knowledge about stunting by mobile base nutrition education. World Journal of Pharmaceutical and Medical Research 2019; 5: 60-64.

17. UNICEF. 2021. UNICEF Conceptual Framework on Maternal and Child Nutrition. New York: United Nations Children’s Fund.

18. World Bank. 2020. Spending Better to Reduce Stunting in Indonesia. Jakarta: World Bank.

19. dashboard.stunting.go.id