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NUTRITIONAL INTERVENTIONS TO REDUCE STUNTING IN
DEVELOPING COUNTRIES: A SYSTEMATIC REVIEW
Lasrika S Sinaga, Ciciilya Candi, Mardiati Nadjib, Adang Bachtiar
Masters Program in Public Health, Faculty of Public Health,
Universitas Indonesia
ABSTRACT
Background: Childhood stunting remains a major malnutritional problem in developing countries.
Stunting occurred the adverse effects on children's health in the short and long term, including failure
to thrive, impairment of cognitive and motor development, stunted stature, metabolic disorders, and
decreased intellectual capacity. Integrated nutritional intervention is important to prevent stunting.
This study aimed to identify the nutritional interventions to reduce stunting in developing countries.
Subjects and Method: A systematic review was conducted by searching from Wiley Online Library,
and ProQuest databases. The research question was formulated in PICO-S format: (1) Population, (2)
Intervention, (3) Comparison, (4) Outcome, and (5) Study design. The next step was identification,
screening, and checking the eligibility of the studies. The keywords were nutrition intervention and
stunting reduction. The inclusion criteria were openly accessed and English-language articles
published between 2019 to 2020. The searched articles were conducted identification, screening, and
eligibility. The data were reported by PRISMA flow chart.
Results: Nine articles met the inclusion criteria. Integrated efforts to reduce stunting incidence were
carried out through sensitive and specific nutritional interventions. A holistic approach involving the
non-health sectors had significant impacts. Some limitations had still occurred in the capacity of
implementing qualified nutritional interventions and their utilization.
Conclusion: Implementation of nutritional interventions have been focused in developing countries
with different approaches to reduce stunting incidence.
Keyword: nutritional intervention, stunting, developing countries
Correspondence:
Lasrika S Sinaga. Masters Program in Public Health, Faculty of Public Health, Universitas Indonesia.
Jl. Margonda Raya, Pondok Cina, Beji, Depok, 16424, East Java. Email: lasrikass20@gmail.com.
Mobile: +62 81382375618.
BACKGROUND mostly occurs in low and middle-income
countries. (UNICEF, WHO, World Bank,
The burden of malnutrition throughout the
world is still high. Globally, at least 1 in 3 2020; Hossain et al., 2020).
children under 5 years are not growing opti- Apart from the increasing prevalence of
mally because of nutritional deficiencies: stunting, in 2017, 55% of childhood stunting
stunting, wasting, and overweight. 149 mil- in the world came from Asia and 39% came
lion and 49 million children under five from Africa, most of them entered developing
worldwide suffer from stunting and wasting. countries. Nutritional problems such as
The cause of 3.5 million deaths universally, stunting and other malnutrition are still a big
35% of morbidity among children under five problem that must be addressed, especially in
was malnutrition. The prevalence of stunting developing countries. Stunting is a condition
worldwide decreased from 39.3% to 20.8% of failure to thrive in children under five due
under 5 years of age from 1990 to 2020. This to lack of nutritional intake for a long time as
well as the occurrence of repeated infections.
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These factors are influenced by inadequate To ensure the convergence of these
parenting, especially in the first 1,000 days of interventions, it requires sectoral and non-
life. Stunting, defined as the length or height, health sector commitments, including the
is more than two standard deviations below highest government in each country, political
the WHO median growth standard for child- and policy commitment to implementation,
ren of the same age and sex. (Indonesian and government involvement and capacity to
Ministry of Health, 2018). implement. (Rosha et al., 2016; Indonesian
Stunting poses a risk of physical growth Ministry of Health, 2018). This study aimed
retardation and a child's susceptibility to to review or identify studies related to nutri-
disease. It causes growth failure, cognitive tion interventions in reducing stunting in
and motor development impediments, and developing countries.
not optimal physical body size and metabolic SUBJECTS AND METHOD
disorders in the short term and risks reduc- 1. Study Design
ing productivity in adulthood and intellectual This study was a systematic review conducted
capacity in the long term. (WHO, 2019). This by searching from Wiley Online Library, and
is due to chronic or recurrent malnutrition, ProQuest databases.
usually influenced by poor socioeconomic 2. Population and Sample
conditions, poor maternal health and nutri- Articles were searched using PICO. The
tion, frequent illnesses, and improper feeding population was children aged <5 years with
and care for infants and children early in life. intervention in the form of nutrition to see
(Ministry of National Development Planning the status stunting in children.
/ Bappenas, 2018; UNICEF, WHO, World 3. Inclusion and Exclusion Criteria
Bank, 2020). The inclusion criteria of this study included:
Several factors indirectly affect the 1) Study population with articles on children
nutritional intake and health status of mo- under 5 years; 2) Research journals in de-
thers and children, the social environment veloping countries; 3) Journals, articles in
associated with the practice of feeding infants English and published in the last 1 year; 4)
and children (care), access to services health availability documents (free); and 5) Docu-
for prevention and treatment (health), as well ments published in the field of public health
as environmental health which, includes the and medical science.
availability of clean water and sanitation Exclusion criteria were as follows: 1)
facilities. Intervention on these four factors is Other databases; 2) Use of language except
expected to prevent deficiency or excess of for English; 3) Inaccessible (paid); and Arti-
nutritional problems (UNICEF, 2020). cles published less than 2019.
Nutrition interventions include specific 4. Data Analysis
nutrition interventions and sensitive nutri- This review uses PRISMA (Preferred Re-
tion as a step in reducing stunting as well as porting Items for Systematic Reviews and
overcoming direct causative factors. Sensitive Meta-Analyzes) with eliminating irrelevant
nutrition interventions are for indirect articles using criteria identification, screen-
causes. The implementation of convergent ing and eligibility.
interventions towards priority groups is the The stages in this research consisted of
key to improving nutrition, child develop- identifying research questions, developing a
ment and preventing stunting. systematic review research protocol, deter-
mining the research database as an area to
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search for articles, selecting relevant research (Ministry of Health, 2018; Arriola et al.,
results, extracting data, analyzing, and re- 2020).
porting. Duplication checking via the app DISCUSSION
Mendeley as well as checking back manually.
In response to the high prevalence of
RESULTS
stunting is concentrated in several countries.
A total of 459 articles were found, which were WHO had proposed a global target of reduc-
free of duplication. Furthermore, the feasi- ing the incidence of stunting in children
bility assessment was carried out according under five years of age by 40% by 2025
to the inclusion and exclusion criteria and (WHO, 2019). Stunting reduction through
found 9 articles. The reviewed article was specific and sensitive nutrition interventions
thoroughly adapted to the systematic review was aimed at various activities.
approach as shown in Figure 1. Zaidi et al. (2020) stated that there
This study came from developing coun- were specific nutritional interventions such
tries, including Pakistan, Northwest Ethiopia, as providing food supplementation to prevent
Sindh (Pakistan), Chandigarh (India), Naus- stunting in Pakistan consisting of Lipid-
hahro Feroze (Pakistan), Southern Ethiopia, based Nutrient Supplement (LNS), a mo-
Mumbai, and Benin (Western Africa). Based derate quantity lipid-based nutritional sup-
on the research design, 7 studies used quan- plement (LNS-MQ) developed for the preven-
titative studies and 2 used qualitative studies. tion of malnutrition, locally produced which
Studies showed that the involvement of given to children from 6 to 23 months of age.
all components in fulfilling nutrition is neces- Guidelines for using LNS for the pre-
sary as part of the formulation of efforts to vention of malnutrition are based largely on
improve nutrition with various programs as program circumstances and commodity
well as a country's development planning. availability and highlight the need for more
Stunting is one of the Sustainable Develop- evidence on the impact of different supple-
ment Goals (SDGs) targets, which is included ments on nutritional status in specific cir-
in the second sustainable development goal, cumstances. Powder for sprinkling on food
namely eliminating hunger and all forms of for children aged <5 years or 24–59 months
malnutrition by 2030 and achieving food and Wheat Soy Blend (WSB) (fortified food
security. The target set is to reduce the stunt- made from beans to mix with flour) for
ing rate by 40% by 2025. during pregnancy and 6 months after delive-
The combination of the three aspects of ry (Khan et al., 2020).
specific nutrition intervention efforts, sensi- Apart from providing dietary supple-
tive nutrition interventions and, inter- ments, there were also educational interven-
ventions an enabling environment scale, tions, counseling on early initiation of breast-
according to political needs, capacities, and feeding and exclusive breastfeeding, promot-
opportunities in each context. It is hoped that ing optimal breastfeeding, sustainable breast-
success in the form of increasing nutritional feeding, complementary feeding, and hygiene
status can be achieved. Fulfillment of nutri- practices. WHO recommended exclusive
tional needs can improve the quality of the breastfeeding for babies during the first six
next generation, which will indirectly in- months of life to ensure the baby's optimal
crease significant economic benefits through growth and health (WHO, 2019).
improving the quality of human resources. The next intervention was the promo-
tion of optimal complementary feeding thro-
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ugh behavioral change interventions with tary diversity (MDD) and minimum accept-
complementary feeding. Communication of able die (MAD) but not on minimum meal
changes in complementary feeding behavior frequency (MMF) (Jordan et al., 2018).
delivered through actors at the community Ethiopia had also implemented specific
level significantly increases the adequacy of and sensitive interventions in reducing
baby food (Abiyu and Belachew, 2020). stunting, such as the sustainable undernutri-
Another study supported behavior change or tion reduction activity (SURE) in Ethiopia,
counseling interventions in Malawi to pro- which was a multi-sectoral government-led
mote optimal complementary feeding prac- program for increasing nutritional outcomes
tices primarily targeting caregivers of that specifically focuses on the integration of
children. the health and agricultural sectors. This
Nutrition education interventions were program had been implemented to reduce
designed to facilitate a series of age-appro- stunting by 26% by 2020 and increase
priate food selection, nutrition, diet, child complementary feeding and dietary diversity
feeding, food preparation, water, sanitation, as well as and using a behavior change com-
and hygiene. The intervention showed a munication (BCC) approach (Worku et al.,
significant positive effect on minimum die- 2020).
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