Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 Analysis of the Relationship Between Children's Characteristics, Family
Characteristics, Food Intake, Eating Habits, and Disease History with Nutritional Status of Under-Five Children Based on the Composite Index of Anthropometric Failure in Karangkamulyan Village, Cihara District, Lebak Regency, Indonesia in 2020
Ayu Anisadiyah*, Ratu Ayu Dewi Sartika
Public Health Nutrition Faculty of Public Health Universitas Indonesia, F Building 2nd Floor Kampus Baru UI Depok 16424, Indonesia
*Corresponding Author:
Ayu Anisadiyah
E-mail: [email protected]
Abstract
The Composite Index of Anthropometric Failure (CIAF) is an indicator of composite nutritional status assessment (BB/U, PB/U, and BB/PB) to describe all under-five children’s nutritional problems. In 2020, malnutrition, unemployment, and poverty in Banten Province were high, and the population's income tends to be low. Karangkamulyan Village is an underdeveloped village with mining areas. This study aims to determine the factors related to the nutritional status of under-five children based on CIAF in Karangkamulyan Village in 2020. The study used a cross-sectional study design and a systematic random sampling technique. The research sample was 141 under-five children aged 24-59 months. Data were analyzed by univariate and bivariate (chi-square test). The results of the study found that children under five who experienced nutritional problems based on CIAF were 36.2%. There are three variables related to the nutritional status of under-five children based on CIAF, namely exclusive breastfeeding (p-value 0.026), energy intake (p-value 0.026), and vegetable protein consumption habits (p-value 0.003).
Keywords: Under-five children, CIAF, nutritional status, rural
Abstrak
Composite Index of Antropometric Failure (CIAF) merupakan indikator penilaian status gizi komposit (BB/U, PB/U, dan BB/PB) untuk menggambarkan seluruh masalah gizi balita. Pada tahun 2020, masalah gizi, tingkat pengangguran, dan kemiskinan Provinsi Banten cukup tinggi serta pendapatan penduduknya cenderung rendah. Desa Karangkamulyan adalah desa tertinggal dengan wilayah pertambangan.
Penelitian bertujuan mengetahui faktor-faktor yang berhubungan dengan status gizi balita berdasarkan CIAF di Desa Karangkamulyan pada tahun 2020. Penelitian menggunakan desain studi cross sectional dengan menggunakan teknik simple random sampling. Sampel penelitian adalah 141 balita berusia 24-59 bulan. Data dianalisis secara univariat dan bivariat (uji chi-square). Hasil penelitian menemukan bahwa balita yang mengalami masalah gizi berdasarkan CIAF sebanyak 36,2%. Terdapat tiga variabel yang berhubungan dengan status gizi balita berdasarkan CIAF, yaitu ASI Eksklusif (p-value 0,026), asupan energi (p-value 0,026), dan kebiasaan konsumsi protein nabati (p-value 0,003).
Kata kunci: Balita, CIAF, status gizi, pedesaan
IJPHN
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 Introduction
Indonesia is a country with a serious problem of malnutrition (1). The nutritional status of children in the population can be identified using conventional indexes (WAZ, HAZ, WHZ) or combined index (CIAF). The conventional index cannot determine the widespread problem of child nutrition because each of them only identifies one nutritional problem, namely underweight, stunting, and wasting. In contrast, CIAF can identify all child nutrition problems (2).
In 2018, 58.7% of Indonesian under- five children experienced nutritional problems, 17.7% were underweight, 30.8% stunting, and 10.2% wasting (3).
Research in West Bengal, India, found that 59.1% of children experienced nutritional problems based on a conventional index (16.5% underweight, 27.8% stunting, and 14.8% wasting), while based on CIAF 43.5% of under- five children had anthropometry failure (4). The prevalence difference occurs because under-five children have more than one nutritional problem.
Banten occupies the third highest position in the under-five children’s nutritional problems on Java Island with a total of 53.25% (underweight 16.22%, stunting 26.58%, and wasting 10.45%).
Lebak Regency also ranked third highest in the number of under-five children with nutritional problems, namely 47.27%
(underweight 18.61%, stunting 40.19%, and wasting 9.17 %) (5). In 2020, Banten Province's economy experienced a decline, the unemployment rate and the number of poor people were relatively high, as well as low incomes (6,7). The education level of Banten residents was low, with an average length of school being 6.3 years (8). Karangkamulyan Village is a lagging village with mining areas. The area is on a plateau, and the environment is still red soil and rocks
(9). This condition can cause nutritional problems in under-five children. The unemployment rate, family income, living in rural areas, maternal education, gender, low diversity of food, infectious diseases, non-exclusive breastfeeding, birth weight, and birth length can affect the child's nutritional status (4,10–15).
Therefore, researchers are interested in researching "Analysis of the Relationship Between Children's Characteristics, Family Characteristics, Food Intake, Eating Habits, and Disease History with Nutritional Status of Under- Five Children Based on the Composite Index of Anthropometric Failure in Karangkamulyan Village, Cihara District, Lebak Regency on 2020".
Methods
This study is a secondary study using a cross-sectional quantitative study. The primary research was conducted in September 2020 in Karangkamulyan Village. A simple random sampling method was used in this study. The respondent is the mother of under-five children aged 24-59 months, with a total sampling of 141 children. The research inclusion criteria were under-five children who lived at least 1 year in Karangkamulyan Village, with exclusion criteria, for under-five children who had congenital diseases.
Data collection is done using a questionnaire through interviews and observations. Weight is measured using SECA digital scales with an accuracy of 0.1 kg, and height is measured using microtoise with an accuracy of 0.1 cm.
Weight and height data were processed using WHO Anthro to determine the under-five children’s nutritional status.
The questionnaire used was validated in a different village, namely Cihara Village. The data collected through questionnaires are the child's characteristics (gender), family
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 characteristics (mother's education,
income), children's food intake (energy, protein, fat), children's eating habits (animal protein, vegetable protein, fruit vegetables), and history of the disease (ARI, diarrhea). Data were analyzed by univariate and bivariate by chi-square using the SPSS computer application.
Results
Respondents in this study were 141 under-five children aged 24-59 months.
Table 1 shows the under-five children’s nutritional status based on conventional indexes, 12.1% are underweight, 27.7%
are stunted, 9.2% are wasting, and based on CIAF 36.2% of under-five children have anthropometry failure. The study found that maternal education was predominantly graduated from
elementary school (82.3%), income less than regional minimum wage (97.2%), and male under-five children (51.1%).
Based on their intake, more under-five children were given exclusive breastfeeding (74.5%), less energy intake (89.4%), sufficient protein intake (90.1%), less fat intake (66.7%), frequent consumption of animal protein (58.2%), not frequent consumption of vegetable protein (51.1%), and frequent consumption of fruit vegetables (51.1%).
More children did not have acute respiratory infections (ARI) (73%) and diarrhea (68.8%). Full information can be found in Table 2. The results of the bivariate analysis (Table 3) showed that exclusive breastfeeding, energy intake, and vegetable protein consumption habits had a relationship with the under- five children’s nutritional status.
Table 1. Under-Five Children Nutritional Status 1
Nutritional Status n (%)
WHZ
Underweight 17 (12.1)
Not Underweight 124 (87.9)
HAZ
Stunting 39 (27.7)
Not Stunting 102 (72.3)
WHZ
Wasting 13 (9.2)
Not Wasting 128 (90.2)
CIAF
A (No Failure) 90 (63.8)
B (Wasting) 5 (3.5)
C (Wasting, Underweight) 4 (2.8)
D (Wasting, Stunting,
Underweight) 4 (2.8)
E (Stunting, Underweight) 6 (4.3)
F (Stunting) 29 (20.6)
Y (Underweight) 3 (2.1)
CIAF Total 51 (36.2)
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 Table 2. Respondent Characteristics2
Variable n (%)
Maternal Education
≤Graduated elementary school 25 (17.7)
>Graduated elementary school 116 (82.3) Income
≤Regional minimum wage 137 (97.2)
>Regional minimum wage 4 (2.8)
Gender
Boy 72 (51.1)
Girl 69 (48.9)
Exclusive Breastfeeding
No 36 (25.5)
Yes 105 (74.5)
Energy Intake
Less 126 (89.4)
Sufficient 15 (10.6)
Protein Intake
Less 14 (9.9)
Sufficient 127 (90.1)
Fat Intake
Less 94 (66.7)
Sufficient 47 (33.3)
Animal Protein Consumption Habits
Not often 59 (41.8)
Often 82 (58.2)
Vegetable Protein Consumption Habits
Not often 72 (51.1)
Often 69 (48.9)
Vegetable and Fruit Consumption Habits
Not often 69 (48.9)
Often 72 (51.1)
ARI History
Yes 38 (27.0)
No 103 (73.0)
Diarrhea History
Yes 44 (31.2)
No 97 (68.8)
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 Table 3. Bivariate Analysis Results3
Variable
CIAF Total OR (95% CI) P-Value
Yes No
n % n % n %
Maternal Education
≤Graduated Elementary School 10 40.0 15 60.0 25 100 1.220
(0.503-2.958) 0.834
>Graduated Elementary School 41 35.3 75 64.7 116 100 Income
≤Regional minimum wage 50 36.5 87 63.5 137 100 1.724
(0.175-17.021) 1.000
>Regional minimum wage 1 25.0 3 75.0 4 100
Gender
Boy 26 36.1 46 63.9 72 100 0.995
(0.500-1.978) 1.000
Girl 25 36.2 44 63.8 69 100
Exclusive Breastfeeding
No 7 19.4 29 80.6 36 100 0.335
(0.134-0.833) 0.026*
Yes 44 41.9 61 58.1 105 100
Energy Intake
Less (<100%) 50 39.7 76 60.3 126 100 9.211
(1.174-72.259) 0.026*
Enough (≥ 100%) 1 6.7 14 93.3 15 100
Protein Intake
Less (<100%) 7 50.0 7 50.0 14 100 1.886
(0.622-5.721) 0.400
Enough (≥ 100%) 44 34.6 83 65.4 127 100
Fat Intake
Less (<100%) 37 39.4 57 60.6 94 100 1.530
(0.723-3.238) 0.353
Enough (≥ 100%) 14 29.8 33 70.2 47 100
Animal Protein Consumption Habits
Not Often 17 37.8 28 62.2 45 100 1.107
(0.532-2.306) 0.933
Often 34 35.4 62 64.6 96 100
Vegetable Protein Consumption Habits
Not Often 35 48.6 37 51.4 72 100 3.133
(1.517-6.472) 0.003*
Often 16 23.2 53 76.8 69 100
Vegetable and Fruit Consumption Habits
Not Often 2
9 42.0 40 58.0 69 100
1.648
(0.824-3.294) 0.214
Often 2
2 30.6 50 69.4 72 100
ARI History
Yes 18 47.4 20 52.6 38 100 1,909
(0.893-4.080) 0.138
No 33 32.0 70 68.0 103 100
Diarrhea History
Yes 16 36.4 28 63.6 44 100 1,012
(0.482-2.124)
1.000
No 35 36.1 62 63.9 97 100
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 Discussion
CIAF is an indicator of combined nutritional status assessment using WAZ, HAZ, and WHZ indexes simultaneously. The CIAF can identify one or more child nutrition problems (2).
Based on the conventional index, 12.1%
of under-five children are underweight, 27.7% stunted, and 9.2% wasting, with a total nutritional problem of 49%.
According to CIAF, 36.2% of under-five children experience anthropometry failure. When compared, there are prevalence differences in under-five children’s nutritional problems due to more than one nutritional problem in under-five children.
This study found that factors related to the under-five children’s nutritional status, were exclusive breastfeeding (p=0.026), energy intake (p=0.026), and vegetable protein consumption habits (p
=0.003). Other studies also found that exclusive breastfeeding is associated with the under-five children’s nutritional status (14). Breast milk is the right food for children aged up to 6 months because it can supply all nutritional needs while their digestive system is still developing.
Children who consume breast milk exclusively will meet their nutritional needs optimally (16). The odds ratio obtained is 0.335 (OR<1, p=0.026, CI=0.134-0.833), then exclusive breastfeeding has a negative relationship with the under-five children’s nutritional status. The results showed that under- five children with anthropometry failure were more numerous in the exclusive breastfeeding group. Inter-variable analysis shows that many exclusively breastfed under-five children have less energy intake, leading to unfulfilled current consumption. Nutritional status is the impact of past and current consumption (17). The quality of breast milk also affects the under-five children’s nutritional status, the poor
quality of breast milk can lead to malnutrition even if given exclusively.
The mother's food intake impacts the decreased quality of breast milk (18).
Other studies have also found an association between energy intake and under-five children’s nutritional status (19). The OR value obtained is 9.211 (p=0.026, CI=1.174-72.259), so under- five children with less energy intake have a 9.211 higher risk of experiencing nutritional problems. If the energy intake of under-five children is not met, there will be an energy imbalance. Conditions that last for a long time will cause nutritional problems for under-five children (20). Under-five children will be hampered in their growth and development (21). Inter-variable analysis shows that under-five children with adequate energy intake generally have adequate protein and fat intake. For children with less energy intake, only their protein intake is sufficient. Under- five children consume much more energy, often consume vegetable protein, and do not consume animal protein often. Thus, whether under-five children with sufficient or less energy intake, their protein intake is generally good with frequent consumption of vegetable protein.
Other researchers also found a relationship between plant-based protein consumption and under-five children’s nutritional status (22). The protein recommended consumption is 70% from vegetable protein, so it plays a significant role in a child’s growth and development process (23). The odds ratio value of 3.133 (p=0.003, CI=1.517- 6.472) illustrates that children who consume vegetable protein do not often have a 3.133 higher risk of experiencing nutritional problems.
In this study, several factors were found to be unrelated, including maternal education, income, gender, protein
Indonesian Journal of Public Health Nutrition October 2022, Vol. 3 Issue 1 page 1 - 10 intake, fats, animal protein consumption
habits, fruit and vegetables, ARI, and diarrhea. Other studies also found no association between maternal education and the under-five children’s nutritional status. Nutritional knowledge is acceptable through formal education because not all schools provide nutrition education. Nutrition education can be obtained through the public health center, integrated service posts, the internet, or other sources (15). Education in Lebak District tends to be low, with an average length of schooling of only 6.3 years (8). Another study found income was not related to the under-five children’s nutritional status (24). The low income of the Lebak people causes very few families with good economic status (7). In this study, only 2.8% family had income more than the regional minimum wage. Gender was not associated with the under-five children’s nutritional status in this study, in line with other studies (15). Gender is not related to nutritional status because there is no difference in treatment between boys and girls.
Protein and fat intake are also not associated with nutritional status in line with other studies (25–27). Energy sources other than proteins (carbohydrates and fats) have less effect on anthropometric changes (28). In this study, almost all under-five children, namely 90.1% had sufficient protein intake so it could cause no relationship with the under-five children’s nutritional status. The consumption habits of animal proteins and fruit vegetables unrelated to nutritional status align with other researchers (26). In this study, under-five children tended to consume animal protein frequently (68.1%), and among children with no frequent consumption of animal protein, more children did not experience nutritional problems, namely 62.2% of under-five children. Similarly,
to under-five children who do not consume vegetables and fruits often, more children do not experience nutritional problems (58%).
In line with other studies, disease history (ARI and diarrhea) is not related to under-five children’s nutritional status (29,30). The absence of a relationship between disease history and nutritional status can occur because the mother has prevented the disease and brought the children for treatment to health services (31). The provision of balanced nutritious food by parents can also have an effect (30). The frequency of diarrhea is not frequent, the short duration of diarrhea, and the provision of suitable prevention and countermeasures can cause diarrhea not to affect the children’s nutritional status (31).
Conclusion
Under-five children in Karangkamulyan Village in 2020 who experienced nutritional problems based on CIAF were 36.2%. There is a relationship between exclusive breastfeeding, energy intake, and vegetable protein consumption habits with under-five children’s nutritional status based on CIAF in under-five children in Karangkamulyan Village in 2020.
Acknowledgment
The author is very grateful to the primary data owners who have allowed the authors to use the data to conduct secondary research, namely Nisa Nurul Faizah and Ratu Ayu Dewi Sartika.
This study was approved by The Research Ethics Committee of the Faculty of Public Health Universitas Indonesia (Ethics approval number: Ket- 80/UN2. F10. D11/PPM.00.02/2022).
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