Monitoring and evaluation of childhood stunting reduction program based on fish supplement product in North … – Nature.com

This study provides evidence that the 6-month supplementation program significantly improved the prevalence of stunting in under-5-year-old children in Serdang Bedagai Regency, a newly established Regency in North Sumatra. The one-semester supplementation program initiated by the local government effectively helped the children suffering from stunting to recover, or at least, to improve the condition. The effective improvement was reflected in the improvement of mean HAZ-score and WHZ-score, particularly for children receiving fish-based supplements.

In a study from Jannat et al.12, the supplementation using yogurt in Dhaka found no significance in the mean HAZ-score or WAZ-score compared to the control. The mean HAZ-score improvement was only 0.13 (P-value =0.31). Another study by Stephenson et al.13 in Malawi indicated that 24weeks of supplementation with cowpea (Vigna unguiculata) or common beans (Phaseolus vulgaris) showed no improvement in mean HAZ-score, yet the decrease in mean HAZ-score was observed. In contrast, the delivery of ready-to-use supplements in rural Guinea-Bissau showed effectiveness in improving the mean HAZ-score and mean WHZ-score in 3-month delivery of supplements by 1.310.79 and 0.280.93 in children under 24months, respectively. In older children up to 59months, the improvements of mean HAZ-score and mean WHZ-score were 0.830.52 and0.070.92, subsequently14. Similarly in our study, the improvement of mean HAZ-score and mean WHZ-score of children were found to be 0.971.45 and 1.002.18 in 6-month supplementation.

The dietary intake in children is important, especially animal-based food. The study by Zahariaet al. indicated that animal-based food has a strong correlation with the HAZ-score and stunting in 624months-old children in Nepal and Bangladesh15. Another global literature study from Headeyet al.16 indicated that the area where fish is included in childrens (age 623months) dietary menu owns a mean stunting prevalence of about 19% (7.631.3%). The prevalence was lower than other animal-based diets including eggs only (22.4%) and meal only (24.3%). Animal-source protein including fish also improved HAZ-score among children aged 1236months in rural Malawi (P-value =0.047)17. In addition, the study from Marinda et al.18 in Zambia indicated that there was a correlation between fish consumption and the stunting prevalence in children aged 623months (P-value =0.004). They mainly consume small fish from the speciesLimnothrissa miodonthat is captured from Lake Tanganyika nearby. Children consuming fish were more frequently discovered to be within the normal range of HAZ scores than their counterparts. Yet, the study found that fish consumption has no significant association with WAZ or WHZ scores.

In contrast, the finding in this study is not linear with the finding from the study conducted in Kenya by Konyole et al.19. The study indicated that the fortification of small cyprinid fish calledRastrineobola argenteainto their food did not promote growth and body composition compared with the control. In another study from Cambodia by Skauet al.20, the supplementation conducted using locally available fish (Esomus longimanusandParalaubuca typus) found that the addition of fish in fortified food resulted similarly with control. The proportion of the fortified fish in the functional food and the species of the fish probably affect the insufficiently.

In our study, the local government promoted fish-based supplement obtained from local snakehead fish (Channa striata) that is abundantly available. As one of the fish species with the highest protein contents,C. striatahas become one the most promising protein sources to be used for the prevention and treatment of stunting. This species has been reported to have a high content of protein, complete essential amino acids, fatty acids, and other essential nutrients, which are crucial for childrens growth. In addition, low collagen and high albumin protein contents inC. striatameat also provide high digestibility in babies, children, and elderly people as well as people who are recovering from illness, respectively21. A study by Kundarwati et al. reported that protein intake, zinc and iron significantly correlated with the incidence of stunting in 60 toddlers aged 13 years22. In this regard, 100mL ofC. striataextract was reported to contain high albumin (2.170.14g), zinc (3.340.8mg), and iron (0.200.09mg), which is sufficient to provide albumin for highly demanded such as hypoalbuminemia and growing children. The Zn content in the C. striata extract is also adequate to fulfil the daily requirements of diet intake for toddlers23,24..

The other advantage of using locally provided food is that it reduces the cost of supplementation programs. Although the national government provided nutritious biscuits from the National Supplementary Feeding Program, the availability is limited. The national government also focuses on delivering the biscuits only for children with underweight, thus children with normal weight but stunted cannot access the biscuits supplement. In addition, utilizing fish-based supplements seems to be more promising than biscuits since the improvements in mean HAZ-score and WHZ-score were higher. Although the nutritious biscuit also contained complete nutrients, such as 450cal, 14g of fat, 9g of protein, 71g of carbohydrates, 10 vitamins (vitamins A, B1, B2, B3, B6, B9, B12, D, E and K) and 7 minerals (iron, zinc, phosphor, selenium, dan calcium)4, it effects on mean HAZ-score improvement was not significant It might be explained by several factors such as the absence of appetite and immunostimulant compounds, as well as the lower digestibility of the nutrient in the group.

Another important feature of supplements for stunting is improving the childrens appetite, wherein stunted children often have poor appetite, which may limit their response to nutritional interventions24. TheC. xanthorrhizaandP. niruricontents in the fish-based supplement also probably supported the positive result of the supplementary program from the local government of Serdang Bedagai.C. xanthorrhizaandP. niruriare two herbals that possess appetite stimulant activity25,26.C. xanthorrhizahas been extensively utilized in Indonesia as a medicinal and nutritional plant, which is traditionally used to treat several ailments, including lack of appetite. Major active compounds ofC. xanthorrhizaare terpenoids, curcuminoids, and other phenolic compounds, which have been correlated with its ethnopharmacological properties such as antioxidant, antimicrobial, anti-inflammatory, anticancer and antitumor, antidiabetic, and hepatoprotective25. On the other hand, the active phytochemicals compounds identified fromP. niruriwere flavonoids, alkaloids, terpenoids, lignans, polyphenols, tannins, coumarins, and saponins. Those active compounds have been reported to be effective against Hepatitis B and other viral infections27.

Finally, the result of this research became an insight for local health policymakers to optimize the food that is abundantly available, especially fish-sourced food or other animal-sourced food. The evidence can also be suggestion for the national government to establish a national initiative plan to reduce stunting prevalence in Indonesia28,29. By optimizing the local resources and biodiversity, the rural area could independently eradicate stunting or malnutrition. Some countries including Zambia and Kenya could utilize locally available food sources to supplement the children with stunting and malnutrition18,30. More evidence also revealed that the children living within the area of fish-farming households in Malawi were less prevalent of underweight and malnutrition31.

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