Mayang Sari

Effect of parental formal education on risk of child stunting in Indonesia and Bangladesh: a cross-sectional study

BACKGROUND Child stunting is associated with poor child development and increased mortality. Our aim was to determine the effect of length of maternal and paternal education on stunting in children under the age of 5 years. METHODS Data for indicators of child growth and of parental education and socioeconomic status were gathered from 590,570 families in Indonesia and 395,122 families in Bangladesh as part of major nutritional surveillance programmes. FINDINGS The prevalence of stunting in families in Indonesia was 33.2%, while that in Bangladesh was 50.7%. In Indonesia, greater maternal formal education led to a decrease of between 4.4% and 5% in the odds of child stunting (odds ratio per year 0.950, 95% CI 0.946-0.954 in rural settings; 0.956, 0.950-0.961 in urban settings); greater paternal formal education led to a decrease of 3% in the odds of child stunting (0.970, 0.967-0.974). In Bangladesh, greater maternal formal education led to a 4.6% decrease in the odds of child stunting (0.954, 0.951-0.957), while greater paternal formal education led to a decrease of between 2.9% and 5.4% in the odds of child stunting (0.971, 0.969-0.974 in rural settings; 0.946, 0.941-0.951 in urban settings). In Indonesia, high levels of maternal and paternal education were both associated with protective caregiving behaviours, including vitamin A capsule receipt, complete childhood immunisations, better sanitation, and use of iodised salt (all p<0.0001). INTERPRETATION Both maternal and paternal education are strong determinants of child stunting in families in Indonesia and Bangladesh.

Household Dietary Diversity and Food Expenditures Are Closely Linked in Rural Bangladesh, Increasing the Risk of Malnutrition Due to the Financial Crisis

In Bangladesh, rice prices are known to be positively associated with the prevalence of child underweight and inversely associated with household nongrain food expenditures, an indicator of dietary quality. The collection of reliable data on household expenditures is relatively time consuming and requires extensive training. Simple dietary diversity scores are increasingly used as measures of food security and as proxies for nutrient adequacy. This study examines associations between a simple dietary diversity score and commonly used indicators of socioeconomic status in Bangladesh. Data representative of rural Bangladesh was collected from 188,835 households over 18 rounds of bi-monthly data collection from 2003-2005. A simple household dietary diversity score was developed by summing the number of days each household consumed an item from each of 7 food groups over a 7-d period. The dietary diversity score was associated with per capita nongrain food expenditures (r = 0.415), total food expenditures (r = 0.327), and total household expenditures (r = 0.332) using Spearman correlations (all P < 0.0001). The frequency of meat and egg consumption showed greater variation across quintiles of total monthly expenditure than other items contributing to the dietary diversity score. After controlling for other measures of socioeconomic status in multiple linear regression models, the dietary diversity score was significantly associated with monthly per capita food and total expenditures. Low dietary diversity during the period prior to major food price increases indicates potential risk for worsening of micronutrient deficiencies and child malnutrition in Bangladesh.

Estimating the prevalence of anaemia: a comparison of three methods

OBJECTIVE To determine the most effective method for analysing haemoglobin concentrations in large surveys in remote areas, and to compare two methods (indirect cyanmethaemoglobin and HemoCue) with the conventional method (direct cyanmethaemoglobin). METHODS Samples of venous and capillary blood from 121 mothers in Indonesia were compared using all three methods. FINDINGS When the indirect cyanmethaemoglobin method was used the prevalence of anaemia was 31-38%. When the direct cyanmethaemoglobin or HemoCue method was used the prevalence was 14-18%. Indirect measurement of cyanmethaemoglobin had the highest coefficient of variation and the largest standard deviation of the difference between the first and second assessment of the same blood sample (10-12 g/l indirect measurement vs 4 g/l direct measurement). In comparison with direct cyanmethaemoglobin measurement of venous blood, HemoCue had the highest sensitivity (82.4%) and specificity (94.2%) when used for venous blood. CONCLUSIONS Where field conditions and local resources allow it, haemoglobin concentration should be assessed with the direct cyanmethaemoglobin method, the gold standard. However, the HemoCue method can be used for surveys involving different laboratories or which are conducted in relatively remote areas. In very hot and humid climates, HemoCue microcuvettes should be discarded if not used within a few days of opening the container containing the cuvettes.

Higher Household Expenditure on Animal-Source and Nongrain Foods Lowers the Risk of Stunting among Children 0–59 Months Old in Indonesia: Implications of Rising Food Prices

Because the global financial crisis and high food prices affect food consumption, we characterized the relationship between stunting and nongrain food expenditure at the household level among children 0-59 mo old in Indonesias rural and urban poor population. Expenditure and height-for-age data were obtained from a population-based sample of 446,473 children in rural and 143,807 in urban poor areas in Indonesia. Expenditure on food was grouped into categories: animal, plant, total nongrain, and grain. The prevalence of stunting in rural and urban poor areas was 33.8 and 31.2%, respectively. In rural areas, the odds ratios (OR) (5th vs. first quintile) for stunting were similar for proportion of household expenditure on animal (0.87; 95% CI = 0.85-0.90; P < 0.0001), plant (0.86; 95% CI = 0.84-0.88; P < 0.0001), and total nongrain (0.85; 95% CI = 0.83-0.87; P < 0.0001). In urban poor areas, the relationship between stunting and proportion of household expenditure on animal sources was stronger than in rural areas (OR 0.78; 95% CI = 0.74-0.81; P < 0.0001), whereas the relationship with nongrain was similar to rural areas (OR 0.88; 95% CI = 0.85-0.92; P < 0.0001) and no relationship was observed with plant sources (OR 0.97; 95% CI = 0.93-1.01; P = 0.13). For grain expenditure, OR for stunting in highest vs. lowest quintile was 1.21 (95% CI = 1.18-1.24; P < 0.0001) in rural and 1.09 (95%CI = 1.04-1.13; P < 0.0001) in urban poor areas. Thus, households that spent a greater proportion on nongrain foods, in particular animal source foods, had a lower prevalence of child stunting. This suggests potential increased risk of malnutrition associated with reductions of household expenditure due to the current global crises.

Predictors of maternal and child double burden of malnutrition in rural Indonesia and Bangladesh

BACKGROUND Many developing countries now face the double burden of malnutrition, defined as the coexistence of a stunted child and overweight mother within the same household. OBJECTIVE This study sought to estimate the prevalence of the double burden of malnutrition and to identify associated maternal, child, and household characteristics in rural Indonesia and Bangladesh. DESIGN A total of 247,126 rural households that participated in the Indonesia Nutrition Surveillance System (2000-2003) and 168,317 rural households in the Bangladesh Nutritional Surveillance Project (2003-2006) were included in the analysis. Maternal and child double burden (MCDB) and its association with individual and household characteristics were determined by using logistic regression models. RESULTS MCDB was observed in 11% and 4% of the households in rural Indonesia and Bangladesh, respectively. Maternal short stature [Indonesia (OR: 2.32; 95% CI: 2.25, 2.40); Bangladesh (OR: 2.11; 95% CI: 1.96, 2.26)], and older age were strong predictors of MCDB. Child characteristics such as older age and being female were associated with an increased odds of MCDB, whereas currently being breastfed was protective against MCDB [Indonesia (OR: 0.84; 95% CI: 0.81, 0.84); Bangladesh (OR: 0.55; 95% CI: 0.52, 0.58)]. A large family size and higher weekly per capita household expenditure predicted MCDB [Indonesia (OR: 1.34; 95% CI: 1.28, 1.40); Bangladesh (OR: 1.94; 95% CI: 1.77, 2.12)]. CONCLUSIONS Double burden is not exclusive to urban areas. Future policies and interventions should address under- and overweight simultaneously in both rural and urban developing country settings.

Household Rice Expenditure and Maternal and Child Nutritional Status in Bangladesh

In Bangladesh, poor rural families often deal with high food costs by purchasing primarily rice. Our objective was to characterize the relationship between household expenditure on rice and nonrice foods with maternal and child malnutrition. Food expenditure data and anthropometry were obtained in a population-based sample of 304,856 households in the Bangladesh Nutrition Surveillance Project, 2000-2005. Food expenditures were categorized as rice and nonrice foods and expressed as quintiles of proportional food expenditure. Of children aged 6-11, 12-23, and 24-59 mo, the prevalence of stunting was 33.5, 56.3, and 53.1%, respectively. The prevalence of maternal underweight (BMI < 18.5 kg/m(2)) was 37.3%. Among children aged 6-11, 12-23, and 24-59 mo, rice expenditures were associated with stunting [odds ratio (OR) 1.11, 95% CI 1.02-1.20, P = 0.01; OR 1.09, 95% CI 1.04-1.13, P < 0.0001; OR 1.13, 95% CI 1.08-1.18, P < 0.0001), respectively, among families in the highest compared with the lowest quintile, adjusting for potential confounders, and nonrice food expenditures were associated with stunting (OR 0.87, 95% CI 0.80-0.95, P = 0.002; OR 0.86, 95% CI 0.83-0.90, P < 0.0001; OR 0.89, 95% CI 0.85-0.94, P < 0.0001) among families in the highest compared with the lowest quintile, adjusting for potential confounders. In the highest compared with the lowest quintile, rice expenditures (OR 1.12, 95% CI 1.08-1.15, P < 0.0001) and nonrice food expenditures (OR 0.93, 95% CI 0.90-0.96, P < 0.0001) were associated with maternal underweight. Households that spent a greater proportion on nonrice foods and less on rice had a lower prevalence of maternal and child malnutrition.

Paternal smoking is associated with increased risk of child malnutrition among poor urban families in Indonesia.

OBJECTIVE Paternal smoking is highly prevalent in Asia, and tobacco may account for a large proportion of household expenditures among poor families. We sought to characterise the relationship between paternal smoking, child malnutrition and food expenditures. DESIGN Data on smoking, household expenditures and child malnutrition were examined in a stratified multistage cluster sample of households in the Indonesia nutrition surveillance system. Main outcome measures were child wasting (weight-for-height Z-score < - 2), underweight (weight-for-age Z-score < - 2) and stunting (height-for-age Z-score < - 2), and severe wasting, underweight and stunting (defined by respective Z-scores < - 3). SETTING In total, 175,583 households from urban slum areas in Indonesia. SUBJECTS Children 0-59 months of age. RESULTS The prevalence of paternal smoking was 73.8%. After adjusting for child gender and age, maternal age and education, and weekly per capita household expenditures, paternal smoking was associated with child stunting (odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.08-1.14, P < 0.0001), severe wasting (OR = 1.17, 95% CI 1.03-1.33, P = 0.018) and severe stunting (OR = 1.09, 95% CI 1.04-1.15, P < 0.001). In households where the father was a smoker, tobacco accounted for 22% of weekly per capita household expenditures, with less money spent on food compared with households in which the father was a non-smoker. CONCLUSIONS Among poor families in urban slum areas of Indonesia, paternal smoking diverts household money from food to tobacco and exacerbates child malnutrition.

The potential of various foods to serve as a carrier for micronutrient fortification, data from remote areas in Indonesia

Objective: To estimate the potential of various industrially produced foods, to serve as a carrier for micronutrient fortification based on the frequency of their consumption in different socio-economic strata; to determine the role of fortified instant noodles as a source of micronutrients; to assess the contribution of plant foods, animal foods and fortified foods to vitamin A intake.Setting: A survey was conducted in rural South Sulawesi and urban South Kalimantan between November 1996 and January 1997.Subjects: Households (1500 in South Sulawesi; 2112 in South Kalimantan) were selected randomly by multi-stage cluster sampling. From each household, data were collected from the mother and her youngest child (0–5 y).Data collection: Mothers were interviewed on various topics, including socio-economic status, food consumption, receipt of high-dose vitamin A capsules, health and nutritional status.Results: Monosodium glutamate and salt were consumed daily in almost all households in both areas, and consumption was not associated with socio-economic status. Instant noodles were consumed in nearly all households in both areas, but consumption of fortified noodles was related to socio-economic status; it was highest among households of government employees and private investors, and lowest among farmers and share-croppers. Vegetables were the most important source of vitamin A in rural South Sulawesi, while foods of animal origin were the most important source in urban South Kalimantan.Conclusions: The results support double or triple fortification of salt and/or monosodium glutamate with iodine, vitamin A and/or iron. Efforts to overcome associated technical and logistical difficulties are urgently needed.Sponsorship: Opportunities for Micronutrient Interventions (OMNI); United States Agency for International Development (USAID). European Journal of Clinical Nutrition (2000) 54, 822–827

Paternal smoking and increased risk of child malnutrition among families in rural Indonesia

Objective: To determine whether paternal smoking is associated with an increased risk of child malnutrition among families in rural Indonesia. Methods: The relation between paternal smoking and child malnutrition was examined in a population-based sample of 438 336 households in the Indonesia Nutrition and Health Surveillance System, 2000–2003. Main outcome measures were child underweight (weight-for-age Z score <−2) and stunting (height-for-age Z score <−2) and severe underweight and severe stunting, defined by respective Z scores <−3, for children aged 0–59 months of age. Results: The prevalence of paternal smoking was 73.7%. The prevalence of underweight and stunting was 29.4% and 31.4%, and of severe underweight and severe stunting was 5.2%, and 9.1%, respectively. After adjusting for child gender, child age, maternal age, maternal education, weekly per capita household expenditure and province, paternal smoking was associated with an increased risk of underweight (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01 to 1.05, p = 0.001) and stunting (OR 1.11, 95% CI 1.09 to 1.13, p<0.001) and severe underweight (OR 1.06, 95% CI 1.01 to 1.10) p = 0.020) and severe stunting (OR 1.12, 95% CI 1.08 to 1.16, p<0.001). Conclusions: Paternal smoking is associated with an increased risk of child malnutrition in families living in rural Indonesia.

Purchase of drinking water is associated with increased child morbidity and mortality among urban slum-dwelling families in Indonesia

In developing countries, poor families in urban slums often do not receive municipal services including water. The objectives of our study were to characterize families who purchased drinking water and to examine the relation between purchasing drinking water and child morbidity and mortality in urban slums of Indonesia, using data collected between 1999 and 2003. Of 143,126 families, 46.8% purchased inexpensive drinking water from street vendors, 47.4% did not purchase water, i.e., had running or spring/well water within household, and 5.8% purchased more expensive water in the previous 7 days. Families that purchased inexpensive drinking water had less educated parents, a more crowded household, a father who smoked, and lower socioeconomic level compared with the other families. Among children of families that purchased inexpensive drinking water, did not purchase drinking water, or purchased more expensive water, the prevalence was, respectively, for diarrhea in last 7 days (11.2%, 8.1%, 7.7%), underweight (28.9%, 24.1%, 24.1%), stunting (35.6%, 30.5%, 30.5%), wasting (12.0%, 10.5%, 10.9%), family history of infant mortality (8.0%, 5.6%, 5.1%), and of under-five child mortality (10.4%, 7.1%, 6.4%) (all P<0.0001). Use of inexpensive drinking water was associated with under-five child mortality (Odds Ratio [O.R.] 1.32, 95% Confidence Interval [C.I.] 1.20-1.45, P<0.0001) and diarrhea (O.R. 1.43, 95% C.I. 1.29-1.60, P<0.0001) in multivariate logistic regression models, adjusting for potential confounders. Purchase of inexpensive drinking water was common and associated with greater child malnutrition, diarrhea, and infant and under-five child mortality in the family. Greater efforts must be made to ensure access to safe drinking water, a basic human right and target of the Millennium Development Goals, in urban slums.