Dietary intake of children aged 0.5 to 12 years in Indonesia, Malaysia, Thailand and Vietnam: South East Asia Nutrition Survey (SEANUTS) results
Recommended Dietary Allowance (RDA) refers to the daily intake level of a nutrient that is sufficient to meet the requirements of approximately 97 to 99% apparently healthy individuals in an age- and sex-specific population.1 In addition to anthropometric studies and biochemical analysis, determining a population’s food intake in relation to the RDA is an adjunct in interpreting nutritional status and determining a possible cause of malnutrition.
Several organizations, such as the World Health Organization (WHO),2 Food and Agriculture Organization (FAO),2 Institute of Medicine (IOM),3 European Food Safety Authority (EFSA)4 and European Recommendations Aligned (EURRECA),5 have established human nutrient requirements and recommended nutrient intakes. These recommendations become the basis of individual countries when they develop their own RDA values and create food-based dietary guidelines for their residents.
The SEANUTS is a multicenter cross-sectional study which aims to evaluate the nutritional status of representative samples of children aged 0.5 to 12.9 years in Indonesia,6 Malaysia,7 Thailand,8 and Vietnam (up to 11.9 years only).9 One factor evaluated is the dietary intake of children. Indonesia, Thailand and Vietnam used standardized questionnaires in a 24-hour dietary recall to evaluate dietary intake. Samples of food portions were weighed during data collection to accurately quantify local food products.6,8-9 For Malaysia, dietary intake assessment was done using semi-quantitative food frequency questionnaire (FFQ), where the food items were grouped and the frequency of intake and amount of habitual food consumption were gathered.7
Comparison of dietary intake with the nutrient intake recommendations established for each country helped assess the percentage of children whose daily dietary intake levels were not sufficient to meet their local RDA.6-9
Chronic energy deficiency (CED) is the most widespread nutritional deficiency, affecting almost half of the world’s children. CED is the prolonged intake of energy less than the requirement and is characterized by a drop in body weight, in resting metabolic rate and habitual physical activity.11
Results of the SEANUTS show that more than half of Indonesian children in the urban and rural areas did not meet the dietary requirement for energy, except among urban children in the 0.5 to 0.9 years age group which were slightly below 50%. As children got older, they were more prone to have less energy intake (Figure 1a).6 One third (35% in urban and 30% in rural) of Malaysian children also did not meet the Malaysian Recommended Nutrient Intakes (RNI).7 In Thailand, on average, more than half of the boys and girls (43 to 82%), across age groups did not meet the local RDA5, while in Vietnam, the same observation was made, but higher percentages were seen among rural children (77 to 94%) (Figure 2a).9
Protein is one of the important building blocks of our body. Inadequate intake of protein, especially on a long-term basis, leads to stunting and/or thinning.12 In Indonesia, 45 to 74% of rural children and 28 to 57% of urban children had a protein intake below the local RDA (Figure 1b).6 In Vietnam, 70% of rural children have protein levels below RDA recommendations, which is approximately 1.6 times higher than their urban counterparts (44%) (Figure 2b).9 For Malaysia and Thailand, however, the majority of the children had protein intakes commensurate with their local RDA (Figure 2b).7-8
Essential nutrients, such as iron, calcium and vitamins, are needed by the body for normal functioning. These micronutrients cannot be synthesized by the body or are only produced in small amounts, hence, these have to be supplied through diet.
Vitamin D and calcium are important for bone and teeth development. Inadequate bone mineralization, growth retardation and rickets are consequences of deficient calcium supply.12-13 Only Malaysia had data for Vitamin D intake, the results of which showed that nearly half of children did not meet the recommended nutrient intake for Vitamin D, with a highest percentage (63%) in older rural children.7 For calcium intake among Indonesian, Malaysian and Thai children, more than half did not meet the RDA for calcium.6-9 (Figure 1c, Figure 2c).
Iron is necessary for oxygen transport and brain development. Some studies have associated depleted iron stores with impaired motor and cognitive function.12 Insufficient iron intake has also been a major cause of anemia in children.14 SEANUTS revealed that Indonesia (61% to 92%, urban; 71% to 95%, rural)6 and Vietnam (88%, urban; 94%, rural)9 had higher percentages of children with iron intakes less than the local RDA, compared to Malaysia (63.8%, urban; 27.6%, rural)7 and Thailand (65.1 & 71.5%, urban boys and girls, respectively; 71.5% and 76.2%, rural boys and girls, respectively)8 (Figure 1d, Figure 2d).
Vitamin A is the micronutrient essential for immunity, cell growth and vision.14 Vitamin B1, or thiamine, is responsible for energy metabolism and tissue building.15 Wound healing, resistance to infections, iron absorption and anti-oxidative action are dependent on adequate intakes of Vitamin C.16
In Indonesia, more than half of the children have dietary intakes less than their local recommended levels for Vitamin A and C. An exception was seen among Vitamin A levels of boys and girls who are 0.5 to 0.9 years-old.6 Similar trends were seen for the Vitamin A status among Vietnamese children (77%, urban; 90% rural).9 Three-fourths of Thai children in both urban and rural settings had Vitamin A and C levels falling below their local RDA.8 Surprisingly, Malaysian children had adequate levels of these vitamins, with less than 10% of children having dietary intakes below their local RNI7 (Figure 1e, Figure 2e).
As with energy and protein, micronutrient intake seems to be lower as children get older.3-6 This could be attributed to less dietary intake but having more expenditure of energy as school work and other activities get more demanding.
Low dietary intakes of macro- and micronutrients contribute to a high prevalence of undernutrition and low values of biochemical parameters in children in all age groups. The FAO, in collaboration with other agencies such as WHO, United Nations Children’s Fund (UNICEF), World Food Programme (WFP), must facilitate the formulation of more effective health and nutrition programs and ensure better policies, planning and implementation of these programs. Nutritional strategies that they could further enrich include Scaling Up Nutrition (SUN) movement’s food fortification and micronutrient supplementation and emphasis on food security, family farming and sustainable and resilient food system (UN’s Zero Hunger Challenge).10 In addition, collaboration between the public and private sectors may be beneficial in the development of food fortification programs in Southeast Asia. The private sector can provide financial and technical support in food production and creating joint researches to investigate the efficacy and effectiveness of these fortification programs. Public-private partnerships (PPP) can also strengthen food intake data collections and use of data from both sectors to arrive at more accurate estimates.17
- Recommended Dietary Allowances, 10th ed., 1989. http://www.nap.edu/read/1349/chapter/2
- Dietary recommendations/Nutritional requirements. http://www.who.int/nutrition/topics/nutrecomm/en/
- European Food Safety Authority. Scientific Opinion on Principles for deriving and Applying Dietary Reference Values. EFSA Journal 2010; 8 (3): 1458.
- Dhonukshe-Rutten RA, Bowman J, Brown K et al. Critical Review in Food Science and Nutrition 2013: 53: 10, 999-1040. EURRECA. Evidence-Based Methodology for Deriving Micronutrient Recommendations http://dx.doi.org/10.1080/10408398.2012.749209
- Sandjaja S, Budiman B, Harahap H et al. British Journal of Nutrition 2013; 110: S11-S20.
- Poh BK, Ng BK, Haslinda MDS et al. British Journal of Nutrition 2013; 110: S21-S35.
- Rojroongwasinkul N, Kijboonchoo K, Wimonpeerapattana W et al. British Journal of Nutrition 2013; 110: S36-S44. (Internal Data: Ng SN, Tan-Khouw I, Parikh P, et al. SEANUTS 2.0 Substantiation document, 2013: Version 1.9. 2013)
- Nguyen BKL, Thi HL, Do VAN et al. British Journal of Nutrition 2013; 110: S45-S56.
- Norgan NG. International dietary energy consultancy group, 1987. http://archive.unu.edu/unupress/food2/UID08E/UID08E09.htm
- International Life Sciences Institute Southeast Asia Region. Recommended Dietary Allowances. Harmonization in Southeast Asia. Monograph Series; Tee ES, Florentino RF ed. 2005.
- Khor GL, Chee WSS, Shariff ZM et al. BMC Public Health 2011; 11: 95.
- Nutrition. Micronutrient deficiencies. http://www.who.int/nutrition/topics/en/
- FAO Corporate Document Repository. Human nutrition in the developing world. http://www/fao.org/docrep/W0073e/w0073e05.htm#P2936_334096
- Scurvy and its prevention and control in major emergencies. 1999. United Nations High Commissioner for Refugees. Geneva: World Health Organization.
- Gayer J, Smith G. Nutrients 2015; 7 (1): 646-658.