kemiskinan, hidden hunger, stunting dan...

KEMISKINAN, HIDDEN HUNGER, STUNTING DAN FORTIFIKASI

Prof.(Em) Soekirman

YAYASAN KEGIZIAN UNTUK PENGEMBANGAN FORTIFIKASI PANGAN DI INDONESIA (KFI)

Webinar November 2020

PROF. SOEKIRMAN KFI & INSTITUT GIZI IND (IGI) JKT NOV 2020

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THE STUNTING SYNDROME• “Although stunted children are identified by comparing their

height to an age- and sex-matched reference population, short stature is not usually in itself problematic.

• Instead, we view this condition as a ‘stunting syndrome’ in which multiple pathological changes marked by linear growth retardation increase morbidity and mortality and reduce physical, neurodevelopmental and economic capacity. The short-, medium- and long-term sequelae of stunting,”

* Stunting juga sindroma kemiskinan - “Stunting is the Face of Poverty” (Sri Mulyani Indrawati, WB Blogs 6/6/13)

European Commission - EC, Landell Mils & Global Alliance For Improved Nutrition –GAIN, 2016, Food Fortification Global Mapping Report )


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The stunting syndrome in developing countries Andrew J Prendergast and Jean H HumphreyPaediatr Int Child Health. 2014 Apr; 34(4)

Food

EBF (Food)CFood

Food

Food

PROF. SOEKIRMAN KFI & INSTITUT GIZI IND (IGI) JKT NOV 2020 3

https://www.ncbi.nlm.nih.gov/pubmed/?term=Prendergast%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=25310000

https://www.ncbi.nlm.nih.gov/pubmed/?term=Humphrey%20JH%5BAuthor%5D&cauthor=true&cauthor_uid=25310000

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232245/

Food or Diet, Diet…Diet is the Culprit

• Stunting is primarily caused by Inadequate Quality of Foods/ Diets, primarily lack of Micronutrients, especially : I, Fe, Vitamin A, Zn, Folic Acid – (Hidden Hunger)

• Diet that lack of Calorie and Protein , could cause Hunger. Diet with inadequate Micronutrients could cause Hidden Humger (“Kelaparan Tersembunyi”)

• Hunger related to quantity of diet, measured by Total Calories. Hidden Hunger related to quality of diet , measured by the adequacy of micronutrients


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Hidden Hunger Global Magnitude(S. Muthayya,J.H.Rag et al, 2012,journals.plos.org)

• 2 billion hidden hunger , esp young children &women reproductive age in developing countries

• Micronut Def – 7 percent global disease burden• Mild and Moderate Def. (Indonesia- %>30) :– detrimental effects on human functionality and

productinity. – Iron def leads to impaired physical and cognitive in

ingfant and U5C, adult productivity


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Magnitute of Hidden Hunger (Zn,Fe,Vit A, Iodine Deficiency)2 billion people

Iodine Def

(S. Muthayya,J.H.Rag et al, 2012,journals.plos.org)


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When , Who , Why - Diet Matters

• Related to Hidden Hunger and Stunting, diet matters primarily during the First 1000 Days in Life (1000 HPK- Ind) (green errow in the circle)

• Who – primarily the POOR• Why the poor . Let’s see what the poor eats.


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“The key difference betwen what poor people and everyone else eat”

(Roberto A. Ferdman , Washington Post, September 17, 2015)

• Study on the impact of food stamp program for poor people in USA (1970-2010) : what sources of Calories they (food stamp) eat compared to non food stamp people (not poor)

“The good news is that the nearly 50 million Americans who participate in the food stamp program are getting as many calories in food, on average, as everyone else. (“non poor”)

• The bad news is that those calories are coming from much less healthy things.” (Ferdman,WP)


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https://www.washingtonpost.com/people/roberto-a-ferdman/

What “Food Stamps” People eat in USAPercent Change in Average Daily percapita calories (1970-2010)

(1970 value = 100) (R.Ferdman, Washington Post, Sept 2017)

FAT & OIL

FLOUR & CEREAL

Unhealthycalorie(Empty Cal)-Marion

Healthy Cal

POOR

NON POOR

1970 value=100


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The effect of income on diet(Engel’s Law and Bennet’s Law on Consumption)

Timmer & Falcon, 1973, Food Policy Analysis, WB Document

• The poor spent most of their income on food, less on others (non food)

• The poor spent most of their income on staple food rich in carbohidrate (CHO) as main source of calories, very little on protein, and almost nil on vitamin and mineral -expensive

• The higher the income percent spent less on unhealthy (“empty”calories) and more on healthy (more variation) calories

• The poor are more prone to hidden hunger


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The Effect of Income on Diet(Engel’s Law and Bennet’s Law)

Rich(much variation)

Poor(less or no variation)

% CHO calories % Animal &Veg Protein cal

% suga cal

% Animal &Veg, Fat Calincome

% Calories


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• THE POOR ARE ALWAYS THE MAIN VICTIM OF MALNUTRITION AND HIDDEN HUNGER

• WHAT GLOBAL NUTRITION PROGRAMS HAVE BEEN IMPLEMENTING FOR THE POOR?

• WHAT THE ROLE OF FOOD FORTIFICATION


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Global Strategy in Dealing withMicronutrients Deficiency (Hidden Hunger)

FOOD BASED & NON FOOD BASED INTERVENTIONS

FOOD BASED INTERVENTION 1. Nutrition Education (Balanced Diet- Gizi Seimbang.

Weakness : The poor cannot afford. (Not pro poor)2. Food Supplementation , -targeted program for infants ,

(MP-ASI), young chidren, mothers at MCH/Puskesmas/Posyandu

3. Food Packages for the Poor . Mostly only Calories from Stale Food (rice and noodle), and cooking oil. All are empty or unhealthy calories (not fortified)


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Food Based Intervention……. Food Fortification & Biofortification• Mandated Food Forfification of Staple Foods & Condiments,

a Blanket Approach for every one poor non poor – “no one left behind”- Main Souces of Calories : Rice, Wheat Flour, Cooking oil, and Condiments - Salt) – for every one- (poor and nonpoor) - no one left behind (SDGs) – blanketed approach

* Biofortification - Enriching the Cereal & Tuber Agricultural Outputs , as main staple foods , with essential Vitamin and Mineral (Vit.A, Fe,Zn) though Plant Breeding Technology

• Food Package Assistance (Sembako) with Healthy (Fortified) Calories – For certain/identified groups of poor people

• Food Supplement (fortified) for a special target population (Infants, Young Children, Pregnant and Lactating Women


Non Food Based Intervention

Targeted Program, especially for infants, young children, pregnant and lactating of poor families:

• High dose vitamin A capsule for UFC twice per year• FeFA for women/ pregnant & lactating women• Multi Micronutrient Supplement (MMS) for certain

groups of women

Blanket Program : Water and Sanitation• Positive Correlation Water, Open Latrines and

Stunting (WB Blogs, 2017). .


Complementary ActionsPreventing Micronutrients Malnutrition

(Hidden Hunger)

FORTIFICATION(Food Industry) Blanketed

SUPLEMENTAtiON(fortified foods, vitamins, minerals)Targeted

Nutrition EducationBalanced Diet (Gizi Seimbang)(Family - difficult for the poor)

BIOFORTIFICATION(Agriculture)

WATER & SANITATION

Sumber : Modified from :, Landell Mils & Global Alliance For Improved Nutrition –GAIN, 2016, Food Fortification Global Mapping Report )

1

3

2

45.

COVERAGE


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Apa Fortifikasi & Biofortifikasi?• Fortifikasi Pangan

– Satu upaya meningkatkan nilai gizi suatu atau beberapa jenis bahan makanan dengan menambahkan satu atau beberapa zat gizi tertentu dengan suatu teknologi pengolahan industri pangan.

– Biofortifikasi tujuannya sama dengan fortifikasi biasa, hanya caranya tidak melalui industri pangan tetapi melalui petani. Dengan teknologi plant breeding (pemulyaan tanaman) dicari atau diciptakan bibit padi-padian yang unngul dan dapat menghasilan bulir padi yang tidak hanya berisi tepung (karbohidrat) tetapi juga mengandung Fe, Zn dan vitamin A. Petani akan menikmati beras berkalori sehat karena mengandung vitamin dan mineral.

– Pangan berfortifikasi harus memenuhi persyaratan peraturan mutu dan keamanan yang ditentukan oleh pemerintah dan atau lembaga internasional yang terkait.


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Siapa Yg Perlu Fortifikasi– Terutama Rumah Tangga Miskin termasuk petani

miskin– Mengapa? • Hukum Ekonomi – makin miskin, sumber kalori makin

tinggi CHO dan lemak jenuh, makin sedikit protein. Tanpa atau minim Vitamin dan Mineral.• Orang kaya, pola makan makin mampu makin beraneka

ragam. * Fortifikasi mencoba menganeka ragamkan nilai gizi

makanan yang ada di RT Miskin tanpa atau sedikit tambah uang belanja dan tanpa merubah cita rasa makanan.


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Kriteria Bahan Pangan Fortifikasi Wajib (WHO, 2006)

1. Dikonsumsi secara teratur dan terus menerus dalam jumlah kurang lebih sama oleh sebagian besar penduduk, termasuk penduduk miskin.

2. Bahan pangan tersebut diproduksi oleh pabrik produsen yang jumlahnya terbatas, agar mudah dilakukan pengawasan.

3. Tersedia teknologi fortifikasikasi untuk bahan pangan tersebut.

4. Bahan pangan yang telah difortifikasi harus memenuhi beberapa syarat sbb:


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Kriteria ………………..a) Tidak berubah rasa, bau, warna dan konsistensib) Telah lulus uji Efikasi (“kemanjuran”) dan uji Efektivitas (“kemanfaatan di

masyarakat”)c) Tidak merubah harga yang memberatkan konsumen miskin, sehingga tidak

bersedia membelid) Untuk memastikan kemanfataan fortifikasi dalam waktu tetap signifikan,

dalam jangka waktu tertentu yang ditentukan oleh tim pakarbersangkutan, perlukan dilakukan monitoring berkala mutu(kadar) fortifikan dalam makanan dan dampak bagi kesehatandi masyarakat konsumen.

e)Dampak fortifiksi Wajib lebih nyata bagi penduduk miskin , dari pada sukarela.

(Catatan : Fortifikasi terigu Indonesia tahun 2012 dinyatakan tidak efektifmenurunkan angka anemia, karena ada kasalahan formula fortifikan.Kesalahan ini sudah diperbaiki untuk fortifikasi terigu mulai tahun 2021)


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Fortifikasi Wajib Lebih Efektifdan Lebih Adil

(Helena Pachon, 2016, National Summit Meeting Food Fortification, FFI New Delhi)

Sukarela

Wajib- AFolat lebihtinggi


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Fortifikasi Sukarela

• Penentu fortifikasi dapat pemerintah untuk memperoleh sertifikat Standar Nasional Indonesa (SNI), dapat juga oleh produsen sendiri (tanpa SNI)

• Sasaran, siapa saja yang dapat dan mau membeli• Tujuan menambah nilai sosial produk. Kadang-

kadang diiklankan memperbaiki gizi, tetapi tanpa bukti ilmiah.

• Fortifikasi sukarela tidak atau sedikit dampak pada perbaikan gizi, terutama pada masyarakat miskin.


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Potensi Manfaat Fortifikasi Pangan pada 1000 HPK

Sumber : European Commission - EC, Landell Mils & Global Alliance For Improved Nutrition –GAIN, 2016, Food Fortification Global Mapping Report )

1000 HPK

1

2

3

1.Kehamilan:KeburuhanJanin TinggiJumlah makanan cukupPotensi manfaat Tinggi

2.0-6 bl : Dampak pada ASI,lewat makanan ibu.Kebutuhan tinggiMakanan ibu tidak cukupPotensi manfaat tinggiPotensi memenuhi kebutuhanbayi - rendah

3.6-24 bl : Kebutuhan sangattinggi. Jumah makanan kurangPotensi manfaat rendah


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Bill & Melinda Gates Foundation (2017) & World Bank (2006)

• Food Fortification is Powerful Proven Toolto Fight Hidden Hunger,

• Food Fortification is the Most Cost Effective Nutrition Intervention to Reduce Undernutrition including STUNTING

• Dll


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Sedikit Sejarah Fortifikasi(Helena Pachon, 2016, National Summit Meeting Food Forticication, FFI New Delhi)

VIT A dlm Margarin DENMARK 1917

IODIUM DLM GARAM 1920In USA & Swiss


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Sejarah fortifikasi Indonesia(Garam, Terigu, Minyak Goreng)

•Fortifikasi Garam – Wajib PN Garam Madura garam 1927 oleh Pem Belanda. – Sejak merdeka 1945 sp 1960an tidak ada fortifikasi– Wacana perlunya fortifikasi garam dimulai tahun 1970-1990an oleh beberapa ahli gizi

senior al Darwin Karyadi, Ig.Tarwotjo, Djumadias. Soekirman dan Sunawangdidukung oleh Bappenas, KemKes, KemPerindag dan UNICEF, dilakukanpembahasan, percobaan lapanagan

– 1994 dikeluakan INPRES Wajib fortifikasi garam, berlaku sampai sekarang.

• Fortifikasi tepung Terigu : • UU Pangan 1996, al menyebutkan perlunya pengayaan (fortiifikasi)• Fortifikasi dibahas dalam Widyakarya Pangan dan Gizi VI 1998• 1998 - Proses percobaan fortifikasi di pabrik (Bogasari)• 2001-2019 Kem Perindag SNI Wajib Fortifikasi tp trigu • 2020 Pandemi Covid 19 SNI Wajib Trigu dibekukan sementara

•Fortifikasi Minyak Goreng Sawit dengan Vit A• 2008 : Percobaan di Baranglompo Makasar• 2010 -2015 Scaling Up nasional dengam bantuan GAIN• 2015 Kemenperin mengeluarkan SNI Wajib MGS dengan Vit A• SNI Wajib ditunda pelaksanaannya 2016-2020


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Fortifikasi Wajib Telah Dilaksanakan di Lebih Dari 200 Negara (2016)

(Helena Pachon, 2016, National Summit Meeting Food Forticication, FFI New Delhi)

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in over 200 countries


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49 Negara Laksanakan Fortifikasi Wajib MG DenganVitamin A Untuk Menyehatkan Rakyatnya

JAKARTA NOVEMBER 2020

?

Sumber : European Commission - EC, Landell Mils & Global Alliance For Improved Nutrition –GAIN, 2016, Food Fortification Global Mapping Report )


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JAKARTA NOVEMBER 2020 PROF. SOEKIRMAN KFI & INSTITUT GIZI IND (IGI) JKT NOV 2020

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Referensi • Andrew J Prendergast and Jean H Humphrey Paediatr Int Child Health. 2014 Apr; 34(4)• Hidden Hunger Global Magnitude

(S. Muthayya,J.H.Rag et al, 2012,journals.plo• The key difference between what poor people and

everyone else eat”(Roberto A. Ferdman , Washington Post, September 17, 2015)s.org)

• The Effect of Income on Diet Engel’s Law , C.P. Timmer, WP Falcon and SR Pearson, 1973, Food Policy Analysis, WB Publication.

• European Commission - EC, Landell Mils & Global Alliance For Improved Nutrition –GAIN, 2016, Food Fortification Global Mapping Report )

• Food Fortification Guidelines & Best Practices, World Bank , 2017• Successful Fortification, in Enriching Life, World Bank, 1994• Food Fortification Guides, WHO, 2006• The Future Global Summit on Food Fortification, GAIN, Tanzania, 2015• Strategic Planning for Food Fortification Indonesia, 2005=2015, KFI, Worskhop Cisarua 2004• Fortifikasi Pangan , 2015, Soekirman , D.Martianto, K.Airessa, KFI



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https://www.ncbi.nlm.nih.gov/pubmed/%3Fterm=Prendergast%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=25310000

https://www.ncbi.nlm.nih.gov/pubmed/%3Fterm=Humphrey%20JH%5BAuthor%5D&cauthor=true&cauthor_uid=25310000

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4232245/

https://www.washingtonpost.com/people/roberto-a-ferdman/

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