lessons learnt from tts: different approaches in dealing with stunting preventions
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Lessons learnt from TTS: Different Approaches in dealing with stunting preventionsTRANSCRIPT
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
[CELLRANGE]
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0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60
Perc
ent
of
ho
use
ho
lds
that
can
af
ford
LA
CO
N d
iet
Prevalence of stunting
[CELLRANGE]
[CELLRANGE]
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0
10
20
30
40
50
60
70
80
90
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10 20 30 40 50Pe
rcen
t o
f h
ou
seh
old
s th
at c
an
affo
rd L
AC
ON
die
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