Irregular dietary habits as a predictor of stunting occurrence among children under 5 years of age: a literature review
Article Category: Review
Published Online: Mar 26, 2024
Page range: 17 - 22
Received: Apr 13, 2023
Accepted: Aug 29, 2023
DOI: https://doi.org/10.2478/fon-2024-0002
Keywords
© 2024 Risnah et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
The growth of children could be inhibited by stunting emergence since it affects both physical and neurocognitive development of the children.1 Inadequate complementary feeding played a vital role of stunt-ing issues, which included low-quality food, safety of food, and improper feeding habits.2 Stunting was led by poor breastfeeding technique, as well as duration and frequency of breastfeeding during the newborn phase.3 Besides, children aged 0-23 months consuming untreated drinks showed high vulnerability of experiencing stunting.4 Children with less protein-energy consumption might potentially have 1.4 times higher risk of stunting.5,6 Low dietary intakes provoked the elevation of global DNA methylation since the macro- and micro-nutrients could not be accomplished.7
Maternal involvement also significantly affected children’s growth and development due to the parenting-style and nutrient fulfillment.8 Inappropriate consumption behavior of a family increased stunting risk by 6.01 times higher among children.9 A nutrition transition to the soft-drinks and snacks was argued to be a predis- position factor of malnutrition’s double burden (children stunting and adults overweight).10 Furthermore, breast-feeding could prevent the severity of stunting and cognitive impairments.11,12 Accordingly, appropriate feeding practice is important to improve health and development of children.13
Stunting intrigued plenty of attention from health professionals worldwide because of its long-term effects on the future children’s life physically, psychologically, socially, and economically.14 Affected children would present poor physical development and learning difficulties, and they have high vulnerability of having infectious and chronic diseases.15,16 A study revealed that stunted children would have cognitive devaluation of about 7% compared with non-stunted children.17 Moreover, the United Nations International Children’s Emergency Fund (UNICEF) estimated that Coronavirus Disease 2019 (COVID-19) pandemic aggravated this malnutrition cases.18 Therefore, this malnutrition indicator was a major focus of international nutrition target in 2025.14
World Health Organization (WHO) reported that stunting among children worldwide reached 22% in 2020, which amounted to about 149.2 million cases.19 South Asia, Southeast Asia, and sub-Saharan Africa were being 3 major regions that had high levels of stunting prevalence.18 This prevalence distinction happened due to geographical discrepancies, which influenced household wealth and parental education.20 WHO also mentioned about 15.3 million children suffered from stunting in the Southeast Asian region in 2020.19 It is predicted that 17% of mortality cases among children <5 years were caused by stunting.21 In Indonesia, around 31.4% of 2236 children, who participated in the South East Asia Nutrition Surveys (SEANUTS), experienced stunting.22 According to the data of the Ministry of Health, Indonesia had 30.8% of stunting children <5 years.23 This percentage indicated that Indonesia had severe public health issues.24 Although this prevalence decreased every year, it was still not significant and needed further intervention to diminish its continuing impact.19,24 Since dietary habits among children were being a predictor of stunting, this study was conducted to explore the illustration of feeding patterns of stunting children using literature review method.
This study was a descriptive narrative research using a literature review approach to explore the dietary habits of children with stunting problems. All the literature review processes employed Guideline Review measurement of Joanna Briggs Institute. Related literatures were obtained from journal databases, such as PubMed, ScienceDirect, Google Scholar, and Dimensions through structured research questions with Patient, Exposure an interest, Outcome or responses (PEO) methods. The structured research question was “How was the characterization of dietary habits among children with stunting problems”? Furthermore, there were some searching keywords, such as “dietary habit or stunting child” and “dietary habit and stunting child.”
There were inclusive and exclusive criteria during the literature research. The inclusive criteria were published research articles from 2018 to 2021, articles’ topics related to the dietary habits among stunting children, and articles had to have their identity (ISSN, DOI, or Volume). Moreover, this study only selected cross-sectional, cohort, and case studies. Articles with quality <50% according to the Guideline Review of Joanna Briggs Institute were excluded from the study. Obtained data were sorted according to their correlation with the Guideline Review of Joanna Briggs Institute. The articles were analyzed further using a synthesis grid table.
According to the 4 chosen online databases, this study gained 2246 published articles from 2018 to 2021 about children with stunting. The screening process was conducted further to eliminate articles with irrelevant titles and abstracts, as well as the unsuitable articles with the research question. This screening obtained 530 related articles, which determined forward from their standard quality based on the Guideline Review of Joanna Briggs Institute. Subsequently, 9 articles were eligible to be reviewed ahead.
A descriptive study by Faisal et al.25 mentioned that children were vulnerable for being exposed to nutrition insecurity. Children often experienced growth rate degradation since they lose their appetite. Stunting became the major nutritional problem among toddlers with a percentage of about 40%, then followed by malnutrition (25%), low birth-weight (18%), and toddlers with low weight (15%). Rice was the most consumed carbohydrate by toddlers, while mackerel fish and eggs were frequently chosen as animal protein source. They commonly eat moringa leaves as fiber source from vegetables, but there was not any fruit intake.
Stunting occurred in 10.4% of 67.5% of nutritional problems among children aged 0–5 years. More than half (68.4%) of respondents of Ginting26 research gained direct breast milk, while 31.6% of children did not get any breast milk from their mother. Moreover, only 46.6% of children received additional food besides breast milk.
A literature review in the Eastern Mediterranean region (EMR) mentioned that children <5 years tended to consume fat and saturated fat more than protein intake, especially in Jordan and Lebanon.27 Children in Lebanon had low consumption of micronutrients according to the recommended dietary allowance (RDA), such as vitamin A, vitamin B12 and B6, vitamin C, vitamin D, thiamin, riboflavin, folate, calcium, iron, iodine, zinc, and niacin. Almost 90% of children in this study aged 2-5 years did not accomplish the RDA criteria of vitamin D intakes. Furthermore, preschool children in Jeddah showed inadequate intake of niacin, vitamins, and potassium. On the other hand, under average intake of iron, magnesium, and calcium occurred among toddlers in the United Emirate Arab. From 1995 to 2012, these nutritional intakes came along with the emergence of stunting (7.3%–21.4%), wasting (1.1%–15.2%), and underweight (1.6%–14.4%) in the EMR.
An observational study revealed 39.32% pre-school children experienced stunting. This case emerged due to the imbalance of nutritional intake and nutritional needs. Consequently, children were susceptible to be exposed to infectious disease since their poor nutritional status. Furthermore, children’s body would fall into severe ill condition if they did not get any nutrition recovery, since infection needed more energy to be defeated.28
Zahara29 conducted a cross sectional study to pre-school children about their dietary habit using Food Frequency Questionnaire (FFQ). This study result found that irregular dietary habits were being the major factor of stunting. Respondents demonstrated poor nutritional status, which became a symptom of imbalanced nutrition. Children tended to consume only carbohydrates and vegetables, while protein, fruit, and milk were consumed rarely. Chicken, egg, and fish were frequently given to the children to fulfill their protein needs. However, children barely ate green vegetables and mostly chose carrots as fiber source.
Risnah and Irwan30 concluded that cultural value and lifestyle influenced feeding pattern to children <5 years. Besides, this study mentioned 7 predisposition factors of stunting based on transcultural nursing theory such as education factor, socio-economic status, technology, government policy, cultural value and lifestyle, family habits, and religiosity.
Bivariate analysis presented the correlation between stunting emergence and some factors, such as gender, history of exclusive breastfeeding, dietary restriction, pressure while eating, and drink desire.31 These factors intrigued stunting cases among almost half children in Kerinci, Indonesia.
An observational study demonstrated that nutritional intake of 40 children aged 2–5 years is 77.23% of energy, 69.82% of protein, 79.74% of calcium, and 68.75% of phosphor. About 67.5% of 40 children experienced infectious diseases in the last 3 months. Ismawati et al.32 explained that their parents had low educational background and their mother did not have any job. This study assumed that all these factors increased the risk of imbalance nutrition hence developed stunting emergence.
Research by Khaerunnisa et al.33 mentioned that only 7.28% of 53 children in Cimahi, Indonesia, had stunting status. On the other hand, the 74% of respondents who showed good nutritional status had great feeding pattern continuously. Parents gave additional food to their children besides breast milk. Besides, parents provided food-adaptation process in the family’s healthy food-intake everyday; therefore, children increase their nutrition status.
According to the related articles’ assessment, dietary habits showed a great correlation with stunting occurrence among children <5 years. It included the dietary pattern and various nutrition intake. Various healthy foods increased the nutritional needs optimization.31 The literature mentioned children’s nutrition intake were dominated with carbohydrates and protein, while the other nutrient sources consumption remained minimal. Besides social-related factors, dietary habits played an important role in children’s growth and development, especially in the first 5 years of life. Parents had to pay attention to their children’s nutrient intake during childhood since this period was a golden period. Besides, appropriate feeding would prevent children from various diseases.33 Although parents have a great understanding of high nutritional food, improper feeding pattern would not support nutrient accomplishment.33
This study demonstrated that children with stunting consumed less nutrition intake, such as carbohydrates, protein, calcium, and phosphor.32 Rice, corn, and cassava were the most chosen carbohydrate sources.25,29 In Indonesia, the society commonly provided high carbohydrate food, rice for example, which was considered to be enough to fulfill nutritional needs.34 Moreover, chicken egg was the most popular animal protein source rather than beef, mutton, or fish.25,29 On the other hand, children only consumed plant-based protein sources occasionally, which were limited kind of plant, such as soya beans, mung beans, and kidney beans.29 According to study findings, a single carbohydrate intake and less protein would put children in the iron deficiency condition. Consequently, the production of hemoglobin was probably disturbed. Low concentration of hemoglobin disrupted nutrition and oxygen distribution to the entire body parts. Hence, body cell development failed since the imbalance of nutrient adequacy. In addition, children likely picked snacks rather than processed food.25,29 This behavior interrupted nutrition fulfilment since snacks had the possibility containing some additional ingredients. Therefore, it needed some food restrictions from parents to avoid snack over-consumption.33
Feeding practice also requires to put attention on various food. Non-stunting children often consumed animal- and plant-based protein about 2–3 times a day with different protein sources.28 However, stunting children had been provided 1–2 times a day animal- and plant-based protein by their parents, for instance, fried eggs, which considered to be simple and high-protein sources. These patterns also happened in the fiber-source consumption. Non-stunting children frequently ate fruits based on their snacking schedule, which was 2 times a day with various kinds of fruits. In contrast, stunting children only consumed their favorite fruits about 2–3 times a week.28 Low intake of vegetables and fruit intrigued less fiber fulfillment, hence provoked constipation among children often-times.25 Furthermore, water intake excessively affected children’s appetite as this enormous amount made their stomach full.31 Therefore, the other important nutrient could not be fulfilled.31
Parenting style showed a strong relationship with nutritional status among children. Parent’s knowledge about nutrition improvement was an essential aspect, especially mothers who provided life nutrition from pregnancy until labor stage.26 Mothers with high educational background had a tendency to monitor their children’s growth and supply breastmilk exclusively. Exclusive breastfeeding was the most important factor in stunting emergence, especially among children <2 years.31,35 Information about healthy feeding practices was accessible nowadays as the high-quality information exchange.36 Therefore, they provided their children with high quality and proper quantity of food right after 6 months of living. On the other side, parents with low educational background would experience difficulties in the food preparation for their children hence disrupted children’s nutrient adequacy.26 The misinformation about child treatment and condensed milk consumption was also drew attention.37 Besides, they tended to give complementary food before children aged 6 months, where children only needed to consume exclusive breastmilk in this period.28
The kinds of food intake often adopted from consumption patterns among society, also depended on the availability of food stocks.25 Eating habits formed from a repetitive eating behavior in a long time. This habitual feeding practice was explained further by Madeleine Leininger’s “Transcultural Nursings theory, which the common habit acknowledged as cultural value.30 Consumption pattern in a family, besides nutrients, was correlated with the family’s cultural values. For example, children aged >12 months required to adapt to their family food optimally due to their high energy exigencies.33 Beforehand, maternal eating behavior during pregnancy supplied influences for their baby’s nutrition.38 Parents, who were able to control their children feeding pattern, encouraged children to obtain their optimum nutritional needs as parents understood children’s food necessary and limit.31
A great relationship between parents and children would enhance good communication, which increased children’s attention and positive value.36 The presence of mother and father had an association to stunting emergence.39,40 Democratic parenting style allowed children to achieve effective communication dynamically based on their needs, hence increased growth rate positively. This kind of parenting style enhanced children to be independent, although parents still had particular controls and restrictions.25 Eating stipulation and pressure had high correlation with stunting incidence among children <5 years.31 Parents, who allowed their children to play or watch television during feeding time, would have high tendency raising stunting children. This could happen since children’s concentration was distracted, which caused some difficulties in identifying the feel of hunger and fullness.33 In addition, parents who provided their children with fast food, snacks, high fat, and sugar would have obese children in the future.27
The amount of food and cultural value among parents were not explored in this study due to less information in the reviewed articles. Further studies need to explain about feeding patterns of children with their own cultural values.
Inappropriate feeding patterns and the variety of food were being a factor of stunting emergence among children <5 years. High consumption of carbohydrates, less animal-based protein, and misunderstanding about intake of sweetened-condensed milk predisposed children to suffer stunting. Moreover, parents held an important role in providing adequate healthy food for their children’s nutrient fulfillment, hence children showed excellent growth and development according to children’s age.