PhD Dissertation on the effectiveness of Intensive Nutrition Education
1. General Introduction
1.1 Outline of the PhD dissertation
This PhD dissertation on the effectiveness of intensive nutrition education (INE) with or without provision of multi micronutrient powder (MNP) for in-home use on the nutritional status of mildly wasted children in community-based setting in Nias Island, Indonesia concentrates on several different aspects in the following chapters. Chapter 1 includes with the general introduction, the relevance of the research, and the objectives of the study. Chapter 2 comprises literature review related with the research topic, the current worldwide situation of malnutrition, the intervention programs for malnourished young children as well as history, theory, and research on nutrition education. Chapter 3 contains a detailed methodology of the research study. Chapter 4 presents the results of the INE study with or without provision of multi micronutrient powder (MNP) for in-home use on the nutritional status of mildly wasted children in Nias Island, Indonesia. Main outcomes of the four different programs for children who reached discharged criterion (RDC children) as well as comparison of nutritional/anthropometric-related outcomes of RDC children and non-RDC children are reported in this chapter. Furthermore, reasons for not reaching discharged criteria are also discussed. Chapter 5 illustrates the impact of educational intervention on the level of knowledge and practice of caregivers of respected children. The comparison of knowledge and practice score of the two different NE type interventions, namely INE and NNE, at admission and after intervention time are also presented. Chapter 6 discusses the role of the two different educational interventions with feeding encouragement models which accompanied locally-produced Ready to Use Supplementary Food (RUF), namely RUF-Nias biscuits, in improving the nutritional status of moderately/mildly wasted children under five years old in Nias Island, Indonesia. Chapter 7 presents the results of dietary intake of mildly wasted children in the study areas. Chapter 8 integrates all previous study results and other related information into a general review and discussion regarding the situation of micronutrients intervention globally. Furthermore, several nutrition education issues specifically dealing with the local setting, was highlighted. General limitations of the study are also presented. Chapter 9 includes the general summary of this study and related recommendations.
1.2 Relevance of the topic
Malnutrition (by means of under nutrition) is a state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth (WFP 2005). It can result from a lack of macronutrients (carbohydrates, protein and fat), micronutrients (vitamins and minerals), or both (WHO/UNICEF 2009; WFP 2005; UNICEF 1998; King et al. 1993). The body has an adaptation mechanism for macronutrient deficiencies by decreasing activity and increasing the use of energy reserves (muscle and fat) or decreased growth. However, for micronutrients malnutrition (hidden hunger) no such compensation mechanism is found considering that vitamins are essential and cannot be synthesis by the own body. This occurs when the vital vitamin and/or minerals are not present in sufficient amounts in the diet (WFP 2005).
The most pronounced micronutrient deficiencies are iron, iodine, vitamin A, and zinc (Bhutta 2008) and the most vulnerable groups suffering from malnutrition are pregnant women and their foetus, lactating women, and children up to the age of three. Furthermore, young children who receive nutritionally inadequate diets and care are more prone to frequent illness, to becoming malnourished (UNICEF 1998).
The first two years of children's lives provide a critical window of opportunity for ensuring children's appropriate growth and development through optimal feeding. Malnutrition during this period of age can cause stunting, leading to the adult being shorter than the potential height (IEG- World Bank 2010). Unfortunately, childhood malnutrition remains a widespread persistent public health problem in the developing countries, particularly in south Asia and Africa (Ashworth et al. 2009; Bhutta et al. 2008; Bhandari et al. 2001; UNICEF 1998). Stunting rates increase significantly at 6 months of age when complementary foods are introduced (Bhandari et al. 2004; Dewey 2001; Guldan et al. 2000; UNICEF 1998). A poor quality and inappropriate quantity of complementary foods as a result of insufficient complementary feeding practices have been identified as the most pronounced causes of malnutrition in young children (Dewey 2001; Bhandari et al. 2004; Shi et al. 2010; UNICEF 1998).
Malnourished children are prone to frequent infections that are more severe and longer-lasting than those in well-nourished and may lead to a spiral of ever-worsening nutritional status (Ashworth et al. 2009). They are also much more likely to die as a result of a common childhood disease than those who are adequately nourished (UNICEF 1998). Additionally, malnutrition in this period of age is also linked to long-term impairment in mental, motor and cognitive development (Grantham-Mc Gregor et al. 1997) by reducing the amount of interaction children have both with those who provide care and the environment (WHO/UNICEF 2009; UNICEF 1998). Delaying psychomotor development and lowering IQ by about 9 points is a well-known impact of iron deficiency anaemia in infancy and early childhood. In addition, varying degrees of mental retardation in young children is caused by iodine deficiency of an expectant mother (UNICEF 1998).
In the developing world, about forty six million children under-five years of age are wasted (low weight for height), 177 million are stunted (low height for age), and 112 million are underweight (low weight for age) (Victora et al. 2010). One third of the estimated 9.5 millions deaths that occurred in 2006 among under-five children are directly and indirectly caused by poor nutrition (WHO/UNICEF 2009).
A survey lead by the Government of Indonesia (GOI) found that the number of underweight under-five children was 18%, whereas stunting and wasting were 37% and 14% in 2007 (MOHRI 2008). Data from Result of National Basic Health Research (Riskesdas) in 2007 revealed that North Sumatra Province was one of the 19 provinces in Indonesia with a higher prevalence of underweight (22.7%) compared to the national prevalence (18.4%); 8.4% were classified as severely underweight (MOHRI 2008).
Every second child in Nias Island in North Sumatra Province was stunted (prevalence of chronic malnutrition 50.7% in Nias, 45.4% in Southern Nias versus 43.1% in North Sumatra and 36.8% in Indonesia) and underweight (prevalence of underweight 51.8% in Nias and 45.8% in Southern Nias versus 22.7% in North Sumatra and 18.4% in Indonesia).
Wasting was also a serious problem in this area. In 2005, a survey lead by UNICEF showed that the prevalence of Global Acute Malnutrition (GAM) in Nias Island varied among districts with a high prevalence found in Southern Nias (17.1%) and oedema was observed among 20 of 24 children who were surveyed. According to CWS (2007), the prevalence of wasting was 11.9% in Nias Island (versus 17.0% in North Sumatra and 13.6% in Indonesia). It is above the emergency threshold of 10% for wasting (Victora et al. 2010; WFP 2005). Therefore, appropriate actions are required to treat severely malnourished cases and prevent moderately or even mildly malnourished children from becoming severe cases in this area.
Anaemia in children (Hb <11.0 g %) is also highly prevalent on Nias Island. Nearly half (51.7% in Nias and 54.0% in Southern Nias) of the children from 6 to 59 months suffer from anaemia (UNICEF 2005) while the country wide data for children under five in Indonesia is 44.5%. The current prevalence of anaemia indicates a severe public health problem.
In Indonesia, sub-clinical vitamin A deficiency (serum retinol 0.35 - 0.7 µmol/L) is still high (~50.0%) in children aged 12-60 months (MOHRI 2003). In 2000, Hadi et al. showed that 15.4% of pre-school children had very low serum retinol concentrations (<0.35 µmol/L) and 52.0% had low serum retinol concentrations (0.35-0.7 µmol/L). A study conducted by Dijkhuizen et al. (2001a, 2001b) in West Java revealed that 54.0% of the children were suffering from sub-clinical vitamin A deficiency. The available data indicate that vitamin A deficiency is a severe public health problem (about 20.0% of values are <0.70 µmol/L) in Indonesia. Up to now, there is no data available about the situation in Nias Island. Lind et al. (2004) and Lind et al. (2003) revealed that 78.0% of children in Central Java had also low serum zinc levels (<10.7 µmol/L). There is lacking data to date on zinc deficiency on Nias Island.
A monotonous diet and certain socioeconomic factors are associated with deficiencies in numerous micronutrients (Wieringa et al. 2001). In many developing countries, diets are mainly cereal-based, low in animal products, and high in phytate, which can increase the risk for micronutrient deficiencies. Dietary deficiencies also develop easily during an emergency situation or can even be made worse if they are already present. Deficiencies are enhanced by or can occur when livelihoods and food crops are lost; food supplies are interrupted; diarrhoeal diseases break out, resulting in malabsorption and nutrient losses; and infectious diseases suppress the appetite whilst increasing the need for micronutrients to help fight illness (WHO/WFP/UNICEF 2006). In Indonesia, deficiencies in iron, vitamin A, and zinc are highly prevalent and often occur together (Dijkhuizen et al. 2001). Considering the high prevalence of anaemia on Nias Island, vitamin A and zinc deficiency may coexist in the same children.
Many various organizations have tried to improve the situation found in Nias Island, but the problem of malnutrition seems to be persistent. For this reason, a multi factorial approach might be appropriate to address the problem, which would include food-based approaches such as food fortification, food supplementation, MNP distribution and non food-based approaches such as nutrition education.
To the best of our knowledge, there is limited information available of the impact of intensive nutrition education (INE) with or without the provision of multi micronutrients powder (MNP) for in-home use on the nutritional status of mildly wasted children on Nias Island. In previous studies, limited information was found on the impact of INE approach to maternal nutrition-related knowledge and practice. However, there is an urgent need to improve nutrition rehabilitation and to develop appropriate nutrition education material based on local needs on Nias Island.
In this study, the impact of INE sessions with mothers of mildly wasted children which was further augmented by MNP for in-home use was investigated. Additionally, the study intended to improve feeding recommendations and assist the development of guidelines for treating mildly malnourished children in Indonesia.
1.5 Conceptual framework of the study
The conceptual framework of this study is presented in Figure 1.2. The study framework proposed the importance of a quality child care in improving the nutritional status of the child. The quality child care was defined to be influenced by feeding practices given to the child. Nutrition education intervention was implemented to increase nutrition-health related knowledge and to promote improved child feeding practices.
MNP Sprinkles was given as home food fortification of daily consumed food and assumed to positively influence appetite and health status of children. The improvement of the nutritional status of the child is influenced by dietary intake and health status. Dietary intake is assumed to be associated with household food security and the quality of child care given by the caregiver/mother. The health status of a child plays an important role to dietary intake (and vice versa). A child's health status is influenced by quality child care and health services /environment.