Dietary Assessment of Children under Five using Calculator of

Inadequate Micronutrient Intake (CIMI) Approach Study Case in

Pandeglang, Banten Province Indonesia

Fetriyuna

1,2

, May Susandy

and Ratna C. Purwestri

Department of Food Technology, Faculty of Agro-Industrial Technology, Universitas Padjadjaran, Jln. Raya Bandung-

Sumedang Km. 21 Jatinangor, Kab. Sumedang 45363, Indonesia.

Institute for Nutritional Science (140a), University of Hohenheim, Garbenstrasse 30, 70599 Stuttgart, Germany

Keywords: CIMI, Micronutrient Intake, Dietary Assessment, Food Groups, Daily Intake

Abstract: Calculator of Inadequate Micronutrient Intake (CIMI Apps) is software to determine the energy, protein, and

micronutrient intakes based on regional dietary patterns. CIMI apps is use to calculate the absolute intake of

energy, macronutrients, retinol, ß-carotene, retinol equivalents, iron, and zinc. CIMI represents an informative

dietary assessment tool to detect nutrient gaps concerning local eating habits based on the food group

classification. Data of 24-hours recall from food intake of 110 respondents of children under five from

Pandegelang district, Banten Province Indonesia was analyzed using CIMI. The result was the percentage of

nutrients covered through the daily diet of the Children. The dietary pattern in that region is characterized by

starchy food (72%), vegetables (12%), and fruits (7%). In addition, a considerable amount of fish and meat

were consumed and a very low portion of dairy products. Every second of children had inadequate

consumption of energy (55.2 %), iron (50%), zink (53%) and almost all the children have inadequate

consumption of vitamin A (98%). The calculation using CIMI delivered information, that on average, the

children’s needs of energy, iron, and zinc were insufficiently fulfilled through their daily intake and extreme

deficiency in the supply of proteins and vitamin A (retinol).

1 INTRODUCTION

The prevalence of undernutrition in Indonesia

remains at a very high level. Based on the report of

Basic Health Research (Badan Penelitian dan

Pengembangan Kesehatan. Kementerian Kesehatan

RI, 2007, 2013 and 2018), the prevalence of stunting

among children under five years of age in Indonesia

were in the range of 30.8% - 36.8%). The proportions

were higher than the whole of Southeast Asia (25.7%)

and even the prevalence globally (22.2%) (UNICEF,

WHO and World Bank Group, 2018) while wasting

is about 10.2% – 13.6% and underweight is at 17.7–

18.4 %. Some programs have been done to overcome

undernutrition through vitamin A supplementation

for children and pregnant women, fortification of

commonly consumed foods, and promotion of

increasing the intake of vitamin and mineral-rich

https://orcid.org/0000-0001-6735-0724

https://orcid.org/0000-0001-5892-4749

foods (ICN2, 2014; Kemenkes RI, 2018; Budiastutik

and Nugraheni, 2018; The SMERU Research

Institute, 2015). Unfortunately, they still need

innovations that can adapt to the specific situation in

Indonesia.

All age groups can be affected by malnutrition,

whereas infants, young children, and pregnant or

lactating women are the most nutritionally vulnerable

groups because of their high physiological and

nutritional requirements. Malnutrition by means of

undernutrition mostly affects children under the age

of five because of their more demanding dietary

requirements. Undernourishment in childhood could

affect the overall cognitive development, school

performance, lifetime earnings, and vulnerability to

infectious and chronic diseases in adulthood (higher

risk of death and illness) (Global Panel on Agriculture

and Food Systems for Nutrition., 2016).

Fetriyuna, ., Susandy, M. and Purwestri, R.

Dietary Assessment of Children under Five using Calculator of Inadequate Micronutrient Intake (CIMI) Approach Study Case in Pandeglang, Banten Province Indonesia.

DOI: 10.5220/0010758600003235

In Proceedings of the 3rd International Conference on Social Determinants of Health (ICSDH 2021), pages 64-69

ISBN: 978-989-758-542-5

Malnutrition (which by means undernutrition) is

usually correlated with insufficient consumption of

nutritious food especially micronutrient deficiencies

(FAO, 1992; Stewart CP, Iannotti L, Dewey KG,

2013; World Health Organization and UNICEF,

2019). Micronutrient deficiencies are believed to

cause more detrimental effects on physical and

cognitive development compared with a calorie

deficit and also creates irreversible of failure growth.

Indonesia has plenty of local food resources,

including numerous tubers, cereals, beans, fruits and

vegetables. Due to the lack of information on the

potential uses and the nutrient contents and the stigma

of being inferior foods, some of them are

underutilized. Many of the underutilized foods are

gaining popularity nowadays because they have

nutritionally rich compounds, which can be used to

combat malnutrition and food and nutrition insecurity

(Durst and Bayasgalanbat, 2014) and (Dandin and

Kumar, 2016).

Food security includes food accessibility and food

availability, was proven to correlate with the

prevalence of stunting in Indonesia ((The SMERU

Research Institute, 2015) and (BMKG, Kementan,

BNPB, LAPAN, BPS, 2017). Data about food

consumption is needed to ensure the possible driven

factors of undernutrition in Indonesia. Table 1

presents the recommendation of nutrients intake of

some of the essential macro and micronutrients for

children up to 6 years old in Indonesia.

To assess the nutritional condition and predict the

micronutrient deficiency, an express instrument is

needed. Calculator of Inadequate Micronutrient

Intake (CIMI Apps) has been used for the rapid

assessment of micronutrient deficiencies in several

countries like Ethiopia (Bosha, Lambert, Riedel,

Gola, et al., 2019; Bosha, Lambert, Riedel, Melesse,

et al., 2019), Ghana (Philipp et al., 2019) and

Indonesia (Radix et al., 2014). This method has

advantages compared to clinical testing for blood or

urine assay which takes a relatively long time and the

action cannot be carried out directly on site.

Table 1. Recommended Nutrient Intake (RNI) Children

Under Five in Indonesia.

Nutrition Unit

Recommended Nutrient Intake

(RNI)

0-6

months

7-11

months

1-3 years

4-6

years

1 Energy kcal 550 725 1125 1600

2 Protein g 12 18 26 35

3 Vitamin A mcg 375 400 400 450

4 Fe mg 2.5 7 8 9

5 Iodine mcg 90 120 120 120

6 Zink mg 2.75 3 4 5

(Ministry of Health RI, 2013)

To assess the nutritional condition and predict the

micronutrient deficiency, an express instrument is

needed. Calculator of Inadequate Micronutrient

Intake (CIMI Apps) has been used for the rapid

assessment of micronutrient deficiencies in several

countries like Ethiopia (Bosha, Lambert, Riedel,

Gola, et al., 2019; Bosha, Lambert, Riedel, Melesse,

et al., 2019), Ghana (Philipp et al., 2019) and

Indonesia (Radix et al., 2014). This method has

advantages compared to clinical testing for blood or

urine assay which takes a relatively long time and the

action cannot be carried out directly on site.

2 METHODOLOGY

Food consumption of 24-h recall was collected from

the respondent of children under five and the data was

entered into the Calculator of Inadequate

Micronutrient Intake (CIMI) program to calculated

the amount of energy intake, protein, carbohydrate,

fats, iron, zinc, pre-formed vitamin A, carotenoids,

retinol equivalents (RE) with a carotenoid conversion

factor of 1:6 or 1:12 and percent of total energy

intake. The individual data will automatically

generate. Percent of the recommended intake of

energy, protein, iron, zinc, and vitamin A intake were

calculated based on the FAO/WHO age- and sex-

specific RNI (Jati et al., 2014).

The data were analyzed using SPSS statistics 22

(IBM, Armonk, NY, USA). The general level of

significance was set at p < 0.05. The results are

expressed in percentages or means-SD/median. Tests

applied were the Kolmogorov–Smirnov test, the

student's t-test/Mann–Whitney test, and univariate

ANOVA/Kruskal–Wallis test.

In order to ascertain amongst which groups a

significant difference was found, the Duncan posthoc

test was performed, or in case of non-normal data the

Mann–Whitney test with subsequent correction of the

Dietary Assessment of Children under Five using Calculator of Inadequate Micronutrient Intake (CIMI) Approach Study Case in

Pandeglang, Banten Province Indonesia

alpha inflation (cumulative Type I error) according to

Bonferroni. To elucidate associations between two

continuous variables, the Pearson/Spearman

correlation was applied. Sets of categorical data were

assessed by Pearson's chi-square test or Fisher's exact

test.

2.1 Ethics Approval and Consent to

Participate

As part of the research about the nutritional condition

of children under five in Banten, the study conformed

to the provisions of the Declaration of Helsinki in

1995 (as revised in Edinburgh 2000). Eligible

children were included only on the basis of the

informed consent of their caretakers. The baseline

study is registered with the study code No:

840/UN6.C.10/PN/2017 at the Health Research

Ethics Committee Faculty of Medicine Universitas

Padjadjaran Bandung, Indonesia (July 28

, 2017) and

approved by the Badan Kesatuan Bangsa dan Politik

(Board of national and political unity) code No:

070/160-kesbangpol/2017 (Oct 2

, 2017). Before

enrolment, a full explanation of the study purpose was

given to the communities, and informed consent was

obtained either by signature or thumbprint.

3 RESULT AND DISCUSSION

The study was conducted from 7

October 2017 until

October 2017 in two villages Kadomas and

Kalanganyar of Banten Province Indonesia. The data

was collected from a total of 105 children (aged 7-61

months) of 56 (53.3%) boys and 49 girls (46.7%). In

regard to the data collection of 24-h recall, 105

caretakers participated. The main caretakers were

mothers (78.2% with 14 are single parents), followed

by 18.1 % grandparents and aunty or other relatives

(3.7 %). Around 53.3% of children recruited in this

study were boys. The majority (76.2%) of the

children lived in a nuclear family.

The age of the children (n = 105) was, on average

31.6 ± 16.0 months at baseline with no significant

difference in the age distribution between both sexes.

The data about the nutritional condition of children

under five were explained in another paper.

3.1 Dietary Intake of The Children

Data of 24-h recall of children under five were

collected during the household visit and the

mother/caretakers were helped to fill the form with

the illustration to predict the total consumed foods.

Table 2 presents the percentage fulfillment of nutrient

consumption which is processed with CIMI apps

from data of 24-h recall. Every second of children

have inadequate consumption of energy (45%),

micronutrient of iron (50%), Zink (53%) and almost

all the children have inadequate consumption of

vitamin A (98%).

There were no differences in consumption

between gender except for iron (p=0.000). The

consumption of energy is not significantly different

among of age group (p=0.19), while shown to a

significant difference for micronutrient iron and zinc

(p=0.000). The inadequate consumption of Iron is

significantly increasing by the age of children, it is

shown that the drastic increase from the age group of

1-2 years to age group 2-3 year from 9% into 21%.

Similarly, with the zinc, or the same age group, the

inadequate consumption increasing from 10% up to

22% in children age 2-3 years. All the age group has

the high level of inadequate consumption of vitamin

A, with the highest of the age group 2-3 years as 28%.

Table 3 presents the fulfillment of nutrients based on

gender and age group of children under five.

The result also confirmed the Fe deficiency was

observed in 4.1–8.8% of the children, the percentage

of children with dietary intakes of energy, protein,

and vitamins A below the Indonesian RNI was high

and differed across urban and rural areas and age

groups (The SMERU Research Institute, 2015;

United Nations Children’s Fund (Unicef), 2018). The

same finding was also funded in India (Meshram et

al., 2012) the health problem among tribal children in

India are associated with food security, food intake,

socioeconomic condition, literacy of parents, and

personal hygiene.

ICSDH 2021 - International Conference on Social Determinants of Health

Table 2. Nutrient Intake of The Children Under Five in The Research Area.

Total n RNI

Mean Sd Median Min Max

Adequate* (%) Inadequate (%)

Energy (kcal) 105 1200 1,196.9 505.9 1,076.6 160.8 2,585.5 58 (55.2) 47 (44.8)

Protein (g) 105 32 33.6 13.6 33.8 4.0 68.2 102 (97.1) 3 (2.9)

Iron (mg) 105 8 4.85 2.8 4.8 0.0 13.1 52 (49.5) 53 (50.5)

Zinc (mg) 105 4 4.9 3.5 4.01 0.4 18.8 49 (46.7) 56 (53.3)

Vitamin A (mg) 105 400 167.8 86.9 164.3 0.0 448.1 2 (1.9) 103 (98.1)

(Ministry of Health RI, 2013)

Table 3. The Dietary Intake and Nutrition Fulfillment Based on CIMI.

Total n Mean Sd Median Min Max

Adequate* (%) Inadequate (%)

by Gender

Energy (kcal) Boys 56 1,207.1 486.4 1107.3 322.9 2,263.5 32 (57.1) 24 (42.9)

Energy (kcal) Girls 49 1,185.2 528.9 1,007.9 160.9 2,585.6 26 (53.1) 23 (46.9)

Protein (g) Boys 56 33.1 13.3 32.8 9.2 68.2 54 (96.4) 2 (3.6)

Protein (g) Girls 49 34.1 13.9 33.8 4.0 59.5 48 (98.0) 1 (2.0)

Iron (mg) Boys* 56 4.9 2.9 5.1 0.0 13.1 31 (55.4) 25 (44.6)

Iron (mg) Girls* 49 4.8 2.8 4.6 0.7 11.1 20 (40.8) 29 (59.2)

Zinc (mg) Boys 56 4.5 2.9 4.1 0.7 16.6 25 (44.6) 31 (55.4)

Zinc (mg) Girls 49 5.3 3.9 3.9 0.4 18.8 24 (49.0) 25 (51.0)

Vit. A (mg) Boys 56 161.7 82.4 157.0 0.0 401.4 1 (1.8) 55 (98.2)

Vit. A (mg) Girls 49 174.6 91.9 174.8 0.0 448.1 1 (2.0) 48 (98.0)

by Age

Energy ≤ 2 year 42 1,080.2 256.3 990.6 160.9 2,585.6 19 (18.1) 23 (21.9)

Energy > 2 year 63 1,278.8 495.8 1,187.9 467.3 2,450.5 39 (37.1) 24 (22.9)

Protein ≤ 2 year* 42 28.0 12.8 25.3 4.0 53.1 39 (37.1) 3 (2.9)

Protein > 2 year* 63 37.4 13.4 35.0 12.2 68.2 63 (60) 0 (0)

Iron ≤ 2 year* 42 3.1 2.4 2.6 0.0 7.6 11 (10.5) 31 (29.5)

Iron > 2 year* 63 6.0 2.7 5.3 0.0 13.1 41 (39.0) 22 (21.0)

Zinc ≤ 2 year* 42 2.8 1.9 2.5 0.4 6.6 8 (15.4) 34 (84.6)

Zinc > 2 year* 63 6.2 3.6 5.7 0.66 18.8 41 (64.3) 22 (35.7)

Vit. A ≤ 2 year 42 171.9 56.7 162.0 2.11 314.0 0 (0) 42 (40)

Vit. A > 2 year 63 173.8 92.5 170.6 0.0 448.1 2 (2.0) 61 (58)

*p-values are significant at p < 0.05

Dietary Assessment of Children under Five using Calculator of Inadequate Micronutrient Intake (CIMI) Approach Study Case in

Pandeglang, Banten Province Indonesia

3.2 Dietary Intake (Food Consumption

and Dietary Pattern)

Based on dietary intake and nutrition fulfillment in

Table 1, only half (55.2 percent) of the children have

the fulfillment of the energy, iron (50.5%) zink

(53.3%) while almost all of them (98.1%) have

insufficient consumption of vitamin A.

Monotonous food consumption which is

dominated by carbohydrate sources (rice, cassava,

and bread) and a small portion of vegetables and

animal food sources resulted from the poor nutrition

of consumption. Children require high value and

diversity of food consumption for optimal growth and

development. Poor diet always comes out with

undernutrition as a result. The study

About the potential of food carrier for

micronutrients in Indonesia also found that the low

food diversity and less animal source, fruit and

vegetables cause the undernutrition in some remote

areas in Indonesia (Melse-Boonstra et al., 2000) low

divers diet of animal source foods (ASF)

(Muslimatun and Wiradnyani, 2016) and dietary

diversity and household food security (Pipi, Nanseki

and Chomei, 2014) and (Meshram et al., 2012).

The government of Indonesia has tried to improve

the micronutrients intake with the regulation of food

fortification (Melse-Boonstra et al., 2000;

Soekirman, Atmarita and Sanjaya, N. Elhusseiny,

2003) of iron in wheat flour and instant noodle; iodine

in salt and monosodium glutamate; vitamin A in oil.

In terms of energy and protein consumption, the

majority of Indonesia population has an adequate (60

%) even more than the normative reference on 50 %

of food consumption, while the consumption of food

derived from tubers, protein from animal sources,

fruits, and vegetables are lower than the ideal or

normative recommendations (Salim and Basuno,

2010). Furthermore, the quality of food consumption

of the Indonesian people is still low due to low food

diversification, nutritionally imbalanced, and unsafe

cause by high contamination.

4 CONCLUSION

Food consumption of children under five in Banten

province Indonesia is dominated by a monotonous

diet in which rice is the main source of carbohydrates

and a low portion of animal source food, vegetables,

and fruits. The fulfillment of energy is sufficient

while deficit in micronutrients (vitamins and

minerals).

REFERENCES

BMKG, Kementan, BNPB, LAPAN, BPS, W. and F. I.

(2017) ‘Buletin Pemantauan Ketahanan Pangan di

Indonesia’, 9, p. 21.

Bosha, T., Lambert, C., Riedel, S., Melesse, A., et al. (2019)

‘Dietary Diversity and Anthropometric Status of

Mother – Child Pairs from Enset ( False Banana ) Staple

Areas : A Panel Evidence from Southern Ethiopia’.

Bosha, T., Lambert, C., Riedel, S., Gola, U., et al. (2019)

‘Validation of the CIMI-Ethiopia Program and

Seasonal Variation in Maternal Nutrient Intake in Enset

( False Banana ) Growing Areas of Southern Ethiopia’,

pp. 1–13.

Budiastutik, I. and Nugraheni, A. (2018) ‘Determinants of

Stunting in Indonesia: A Review Article’, International

Journal Of Healthcare Research, 1(1), pp. 2620–5580.

Dandin, S. B. and Kumar, N. K. K. (2016) ‘Neglected and

Underutilized Fruit Species – an Insurance Against

Global Mal and Under Nutrition’, FAO Regional

Expert Consultation on Scoping, Prioritizing and

Mapping of Neglected and Underutilized Crop Species

in Asia, pp. 1–40. Available at:

http://www.fao.org/fileadmin/templates/rap/files/meeti

ngs/2016/161203_session1_4.pdf.

Durst, P. and Bayasgalanbat, N. (2014) Promotion of

underutilized indigenous food resources for food

security and nutrition in Asia and the Pacific,

Promotion of underutilized indigenous food resources

for food security and nutrition in Asia and the Pacific.

FAO (1992) ‘World Declaration and Plan of Action for

Nutrition’, International Conference on Nutrition,

(December), pp. 1–42.

Global Panel on Agriculture and Food Systems for

Nutrition. (2016) Food systems and diets : Food

systems and diets :

ICN2 (2014) ‘National Nutrition Strategy Paper of

Indonesia’, pp. 1–52.

Jati, I. R. A. P. et al. (2014) ‘Design and validation of a

program to identify inadequate intake of iron, zinc, and

vitamin A’, Nutrition. Elsevier Inc., 30(11–12), pp.

1310–1317. doi: 10.1016/j.nut.2014.03.015.

Kemenkes RI (2018) ‘Buletin Stunting’, Kementerian

Kesehatan RI, 301(5), pp. 1163–1178.

Melse-Boonstra, A. et al. (2000) ‘The potential of various

foods to serve as a carrier for micronutrient

fortification, data from remote areas in Indonesia’,

European Journal of Clinical Nutrition, 54(11), pp.

822–827. doi: 10.1038/sj.ejcn.1601094.

Meshram, I. I. et al. (2012) ‘Trends in the prevalence of

undernutrition, nutrient & food intake and predictors of

undernutrition among under five year tribal children in

India’, Asia Pacific Journal of Clinical Nutrition, 21(4),

pp. 568–576. doi: 10.6133/apjcn.2012.21.4.12.

Ministry of Health Indonesia (2007) ‘Laporan Riskesdas

Nasional 2007’, Riskesdas. doi: 1 Desember 2013.

Ministry of Health RI (2013) ‘Angka Kecukupan Gizi

(AKG) Recommended Nutrient Intake (RNI) of

Indonesia’, Kementerian Kesehatan RI, (mL), pp. 5–10.

ICSDH 2021 - International Conference on Social Determinants of Health

Muslimatun, S. and Wiradnyani, L. A. A. (2016) ‘Dietary

diversity, animal source food consumption and linear

growth among children aged 1–5 years in Bandung,

Indonesia: a longitudinal observational study’, British

Journal of Nutrition, 116(May 2018), pp. 1–9. doi:

10.1017/S0007114515005395.

Philipp, J. et al. (2019) ‘Validation of a computer-based

analysis tool for real-time dietary assessment within a

Ghanaian region’, NFS Journal. Elsevier, 16(April), pp.

15–25. doi: 10.1016/j.nfs.2019.06.002.

Pipi, D., Nanseki, T. and Chomei, Y. (2014) ‘Relationship

between dietary diversity and perceived food security

status in Indonesia - A case of households in the North

Luwu of South Sulawesi Province’, Journal of the

Faculty of Agriculture, Kyushu University, 59(2).

Radix, I. et al. (2014) ‘Design and validation of a program

to identify inadequate intake of iron , zinc , and vitamin

A’, Nutrition. Elsevier Inc., 30(11–12), pp. 1310–1317.

doi: 10.1016/j.nut.2014.03.015.

Salim, H. P. and Basuno, E. (2010) ‘Diversification of Food

Consumption: Its Current Conditions, Problems and

Prospects in Indonesia’, United Nation ESCAP

(Economic Social Commision for Asia and the Pasific),

8 Number 3(ISSN 1693-4636), pp. 1–6.

Soekirman, Atmarita, J. L. O. and Sanjaya, N. Elhusseiny,

F. J. L. (2003) ‘Indonesian Micronutrient Reference

Report’, (19).

Stewart CP, Iannotti L, Dewey KG, M. K. & O. A. (2013)

‘Childhood Stunting : Context, Causes, and

Consequences’, Maternal and Child Nutrition, 9(2), pp.

27–45.

The SMERU Research Institute (2015) ‘Food and nutrition

security in Indonesia : a strategic review. Improving

food and nutrition security to reduce stunting’,

SMERU-UKP4-WFP, p. 89.

UNICEF, WHO and World Bank Group (2018) ‘Levels and

Trends in Child Malnutrition, UNICEF / WHO / World

Bank Group Joint Child Malnutrition Estimates’,

Midwifery, 12(3), pp. 154–155. doi: 10.1016/S0266-

6138(96)90067-4.

United Nations Children’s Fund (Unicef) (2018) ‘Nutrition

Capacity Assessment in Indonesia’, UNICEF, Jakarta,

August.

World Health Organization and UNICEF (2019) ‘The

extension of the 2025 Maternal, Infant and Young Child

nutrition targets to 2030’, Discussion paper, p. 12.

Available at: https://www.who.int/nutrition/global-

target-2025/discussion-paper-extension-targets-

2030.pdf?ua=1.

Dietary Assessment of Children under Five using Calculator of Inadequate Micronutrient Intake (CIMI) Approach Study Case in

Pandeglang, Banten Province Indonesia