Key strategies to further reduce stunting in Southeast

Asia: Lessons from the ASEAN countries workshop

Martin W. Bloem, Saskia de Pee, Le Thi Hop, Nguyen Cong Khan, Arnaud Laillou,
Minarto, Regina Moench-Pfanner, Damayanti Soekarjo, Soekirman, J. Antonio Solon,
Chan Theary, and Emorn Wasantwisut
Abstract
Background. To further reduce stunting in Southeast
Asia, a rapidly changing region, its main causes need to
be identified.
Objective. Assess the relationship between different
causes of stunting and stunting prevalence over time in
Southeast Asia.
Methods. Review trends in mortality, stunting, economic development, and access to nutritious foods over
time and among different subgroups in Southeast Asian
countries.
Results. Between 19902011, mortality among underfive children declined from 69/1,000 to 29/1,000 live
births. Although disease reduction, one of two direct
causes of stunting, has played an important role which
should be maintained, improvement in meeting nutrient requirements, the other direct cause, is necessary to
reduce stunting further. This requires dietary diversity,
which is affected by rapidly changing factors: economic
Martin W. Bloem is affiliated with the World Food Programme, Rome, the Friedman School of Nutrition, Tufts
University, Boston, Massachusetts, USA, and the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; Saskia de Pee is affiliated with the World Food
Programme, Rome, and the Friedman School of Nutrition,
Tufts University, Boston, Massachusetts, USA; Le Thi Hop
is affiliated with the National Institute of Nutrition, Hanoi,
Vietnam; Nguyen Cong Khan is affiliated with the Ministry of
Health, Hanoi, Vietnam; Minarto is affiliated with the Ministry of Health, Jakarta, Indonesia; Arnaud Laillou and Regina
Moench-Pfanner are affiliated with the Global Alliance for
Improved Nutrition (GAIN), Geneva; Damayanti Soekarjo is
affiliated with Santulita Vikasa Consultancy (Savica), Soekirman is affiliated with the Coalition Fortification Indonesia,
Jakarta, Indonesia; Surabaya, Indonesia; J. Antonio Solon
is affiliated with the Nutrition Center of the Philippines,
Manila; Chan Theary is affiliated with the Reproductive and
Child Health Alliance, Phnom Penh, Cambodia; Emorn Wasantwisut is affiliated with the Institute of Nutrition, Mahidol
University, Bangkok, Thailand.
Please direct queries to the corresponding author: Saskia
de Pee, Nutrition and HIV/AIDS, World Food Programme,
Via Cesare Giulio Viola 68/70, 00148 Rome, Italy; e-mail:
depee.saskia@gmail.com.

S8

development; urbanization, giving greater access to larger

variety of foods, including processed and fortified foods;
parental education; and modernizing food systems, with
increased distance between food producers and consumers. Wealthier consumers are increasingly able to access
a more nutritious diet, while poorer consumers need
support to improve access, and may also still need better
hygiene and sanitation.
Conclusions. In order to accelerate stunting reduction
in Southeast Asia, availability and access to nutritious
foods should be increased by collaboration between private and public sectors, and the Association of Southeast
Asian Nations (ASEAN) can play a facilitating role. The
private sector can produce and market nutritious foods,
while the public sector sets standards, promotes healthy
food choices, and ensures access to nutritious foods for
the poorest, e.g, through social safety net programs.

Key words: ASEAN, complementary foods, private

sector, public sector, stunting, undernutrition, dietary

diversity

Introduction
Stunting (short stature for age) is the result of not
meeting nutrient requirements for growth over a long
period of time between conception and 24 months of
age. The presence of stunting indicates that nutrient
intake has been suboptimal not only for growth, but
also for other critical functions of the body, such as
brain development and the immune system. Because
of the critical physical and mental development that
takes place between conception and 24 months of age,
development during this phase determines the individuals potential for life in terms of risks of morbidity
and mortality, school achievement, income earning
potential, physical strength, and risk of chronic disease [1]. This period is called the 1,000-days window
of opportunity. Stunting is the outcome of inadequate
nutrition during this critical developmental phase of

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Key strategies to further reduce stunting in Southeast Asia

life. Because this phase does not reoccur later in life,

reversing or treating the developmental consequences
of early childhood undernutrition later in childhood
is almost impossible. Stunting and its consequences
should be prevented by ensuring access to appropriate
nutrition during the first 1,000 days of life.
The economic consequences of stunting are considerable. Approximately 11% of the health burden
is related to malnutrition [2], leading to increased
healthcare expenditure at both the family and the
national levels. It is estimated that the average income
of a stunted individual is 20% lower than that of someone of average height [3, 4]. A conservative estimate of
the costs of malnutrition to a country is 2% to 3% of
its GDP [5].
For these reasons, stunting prevalence is a very
important indicator of the health and nutrition status of
a population, and stunting prevention is an extremely
important goal, for example, of the Scaling Up Nutrition (SUN) movement [6].
In this paper we assess the trends of stunting prevalence over time in Southeast Asia, explore the underlying causes for the trends and how they have changed
over time, and propose key strategies for a further
reduction, including recommendations that the Association of Southeast Asian Nations (ASEAN) can act
upon.
Trends of stunting prevalence in Southeast Asia

Figure 1 shows the prevalence of stunting in Southeast

Asian countries between 1996 and 2011. By 2011, country prevalence figures ranged from 4% in Singapore
to 48% in Laos PDR. Globally, the prevalence of child
stunting is 26%, with the highest rates in sub-Saharan
50

Direct, underlying, and basic causes of stunting and

trends in Southeast Asia

The UNICEF conceptual framework of malnutrition

(fig. 3) shows that dietary intake and disease are the
two direct causes of stunting, because these factors
represent nutrient intake, and nutrient needs and
utilization, respectively. In turn, these direct factors
are dependent on underlying factors: access to food,
caring practices, healthcare services, and environmental hygiene (water and sanitation), which are all
related to basic causes at the individual and household
levels, such as education and income, as well as societal
factors, including economic situation, gender roles,
governance, etc.
This framework helps us understand the relationship
between GDP and stunting prevalence and the observation that within a country, stunting prevalence is higher

19962005

20002006

20062010

Very high prevalence

40

Prevalence (%)

Africa (40%) and South Asia (39%) [7]. Despite considerable differences among and within countries in
Southeast Asia, and the fact that in all these countries
stunting prevalence was much higher 20 to 25 years
ago, figure 1 does not show a further decline in prevalence in the six countries for which data are available
for three points in time between 1996 and 2011.
Figure 2 shows that Southeast Asian countries with
a higher GDP tend to have a lower prevalence of stunting. However, this does not mean that any country with
a higher GDP than another country also has a lower
prevalence of stunting. For example, Indonesias GDP is
more than twice that of Myanmar, but Myanmar has a
lower prevalence of stunting. Therefore, it is important
to look more closely at how GDP is related to stunting
and how GDP is distributed within a country.

High prevalence

30

Medium prevalence

20

10

Cambodia Indonesia

Lao PDR

Malaysia

Myanmar Philippines Singapore

Thailand

Vietnam

FIG. 1. Changes in stunting prevalence between 1996 and 2010 in Southeast Asian countries [7] with
cutoffs indicating public health problem [8]
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S10

M. W. Bloem et al.
50
Lao

45
40

Cambodia

Prevalence (%)

35

Indonesia

Myanmar

30

Philippines
Vietnam

25
20
15

Malaysia

Thailand

10
5
0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

GDP in PPP$ (purchasing power parity $) per capita (US$)

FIG. 2. Stunting rates by GDP in PPP$ per capita in selected ASEAN countries: 2010 data [7, 9]

Malnutrition

Manifestation

Inadequate
dietary intake

Inadequate
access to
food

Disease

Inadequate care
for mothers
and children

Insufficient health
services and unhealthy
environment

Immediate
causes

Underlying
causes

Inadequate education

Resources & control

Human, economic, and
organizational

Political and ideological superstructure

Basic
causes

Economic structure
Potential
resources
Private
sector

Bilateral
institutions
Multilateral institutions
Development banks
IMF

FIG. 3. UNICEF conceptual framework for the cause of malnutrition (modified by Bloem
et al. [10]).
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16,000

S11

Key strategies to further reduce stunting in Southeast Asia

among groups with lower socioeconomic status (see,

for example, fig. 4). Higher income improves access
to foods, healthcare, and more hygienic circumstances
and can also improve caring practices by increasing
knowledge about care and/or time available for care.
Both disease and nutrient intake can be positively
impacted by these underlying factors, and in that way
stunting can be prevented.
In order to be able to make further progress with
reducing stunting prevalence, we need to understand
which pathways are the most important in particular
contexts, so that the most suitable interventions and
strategies can be identified.
Between 1990 and 2011, mortality among children
under 5 years of age in Southeast Asia declined from
69/1,000 to 29/1,000 live births [13] (fig. 5). With
an average annual decline of 4.1%, Southeast Asia is
50

2007

on track to reach Millennium Development Goal 4.

Although the number of neonatal deaths also declined
during this period, the proportion of deaths of children
under 5 years of age due to neonatal mortality increased
from 35% to 50% [13]. The drastic decline in under-five
mortality is related to the fact that healthcare services,
including antenatal care, immunization, distribution
of high-dose vitamin A capsules, and curative services
for major childhood illnesses, as well as sanitary conditions and access to safe drinking water, have markedly
improved in Southeast Asia over the past 20 years [14,
15]. This also means that, while provision of healthcare
service and hygiene conditions should be maintained
and where possible improved, or its coverage should
be extended to also include the poorest, and efforts to
maintain or improve exclusive breastfeeding up to 6
months and continued breastfeeding until 24 months

2010

Prevalence (%)

40

30

20

10

Urban

Rural

Q1

Q2

Q3

Q4

Q5

FIG. 4. Prevalence of stunting among children under 5 years of age in Indonesia according to urban or
rural location and wealth quintile in 2007 and 2010 [11, 12]
150

1990

2011

Deaths/1,000 live births

120

90

60

30

0
Brunei

Cambodia Indonesia Lao PDR Malaysia Myanmar Philippines Singapore Thailand

Vietnam

FIG. 5. Mortality among children under 5 years of age in Southeast Asian countries in 1990 and 2011 [13]
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S12

M. W. Bloem et al.

of age should continue to be supported, further gains

in improving nutritional status should mainly come
from dietary improvements during pregnancy and
lactation and the complementary feeding period.
Meanwhile, efforts to reduce neonatal mortality will
make an important contribution to further reducing
under-five mortality.
If we look closely at nutrient requirements, many
different nutrients are required besides the ones that
are best knowni.e., energy, protein, vitamins (A, C,
D, and B-complex), and minerals (iron, zinc, iodine)
such as essential fatty acids and essential amino acids,
growth-promoting factors in, for example, milk (insulin-like growth factor), type II nutrients such as magnesium and phosphorus, etc. [16, 17]. These nutrients
are required for growth of muscle tissue and bones,
brain development, and bodily functions such as the
immune system, cofactors for enzymes, etc. Because
these nutrients are present in different foods, dietary
diversity is required to meet nutrient needs [18].
Dietary diversity refers to consumption of foods
from different food groups, including animal-source
foods (dairy, fish, meat, eggs), fortified foods, vegetables, fruits, pulses, staple foods, oil, etc., as well
as breastmilk (exclusive in the first 6 months and
continued until at least 24 months). Also, from within
each food group, different foods need to be consumed.
Fortified foods, or home fortification with micronutrient powder or small-quantity lipid-based nutrient
supplements, are particularly important for meeting
requirements of specific vitamins and minerals, such
as iron and zinc, because requirements are very high
compared with feasible intakes, especially between 6
and 23 months of age [1820].

Factors affecting diet and its relationship

with stunting
As discussed above, a diverse diet, which also includes
fortified foods, is required in order to meet nutrient
requirements and hence prevent stunting, and different
underlying and basic factors can increase access to and
consumption of a more diverse diet. The most important underlying and basic factors, and their changes
over time in Southeast Asia, are discussed below.
Dietary diversity increases as purchasing power
improves

There is substantial evidence for the relationship

between higher dietary diversity and lower prevalence
of stunting [2125]. Whereas Arimond and Ruel controlled their analysis for socioeconomic status [21],
other analyses have shown that increased affordability
and greater expenditure on a larger variety of foods,
in particular nongrain and animal-source foods, are

associated with lower prevalences of underweight [22]

and stunting [24, 25]. An analysis of longitudinal data
on child growth from urban and rural Filipino children collected between 1988 and 1990, showed that
the relationship between socio-economic status and
stunting emerged after the age of 6 months, suggesting
a relationship with nutritional quality of complementary foods. The relationship emerged at the age of 611
months among rural and 1229 months among urban
children [26]. Together, these findings confirm that
dietary diversity, because of improved nutrient intake,
is a key link in the relationship between higher income
and lower prevalence of stunting.
Modernizing food systems

Economic development and improvements in GDP go

together with changes in the food system [2729]. At
one end of the spectrum of food systems are agrarian
societies where the majority of the population grows
food, often as subsistence farmers; there are few possibilities to sell surplus food; there is virtually no food
manufacturing; and only a small proportion of people
buy processed foods, which are usually imported. On
the other end of the spectrum are the food systems of
developed countries, where a very small proportion
of the population grows food, most people buy their
food in supermarkets, and the distance between food
producers and consumers is long, with a large role for
food manufacturers.
As food production is modernized, yields improve,
staple food prices decline, and incomes, throughout the
population, increase. The increase in income and the
lowering of the prices of staple foods lead to increased
dietary diversity, and food systems produce a greater
variety of foods and increase food availability through
increased transport, preservation, and processing by
food manufacturers. It is important to note that many
small-holder farmers are net buyers of food, and that
their incomes improve when they gain better access to
required inputs to improve yields and reduce postharvest losses, and are able to get a better price for their
produce because of better linkage to markets [15, 27].
At the same time, though, we have seen an increase in
food prices across the world since 2008, especially in
countries that import foods, which leads to decreased
dietary diversity [30]. While this process negates some
of the effects of the modernization of food systems,
both processes (modernization of food systems and
increase in food prices) occur simultaneously, but due
to other underlying mechanisms, and they affect different countries and population groups in different ways.
Increased availability and affordability of an
increased variety of foods, including processed foods
and foods with high nutritional value, increases consumer choices and convenience and has been highlighted as one of the major factors in the increase in

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Key strategies to further reduce stunting in Southeast Asia

adult height in Europe in the second half of the 20th

century [31].
The flip side of increased choices and greater availability of a wide range of foods that contribute to an
increased intake of essential nutrients required to
prevent stunting and micronutrient deficiencies is that
the availability of foods that are calorie-dense but low
in essential nutrients (high-fat and high-sugar snacks
and high-sugar drinks) is also higher [27, 28]. Their
consumption, together with an increasingly sedentary
lifestyle, is an important factor in the obesity epidemic
and related disorders of diabetes, cardiovascular disease, and some cancers. In Asia, the poor have a higher
risk of both childhood stunting and, particularly
among adults, overweight and obesity, because their
diet tends to have a low micronutrient content as well as
a relatively high content of foods that are calorie-dense
but low in essential nutrients (e.g., white rice, refined
cereals, high-sugar and high-fat snacks, together with
few vegetables and fruits, animal-source foods, and
fortified foods) [15, 28, 32].
Urbanization

The prevalence of stunting is lower in urban than in

rural populations [26, 33] (see also fig. 4); this has also
been observed when the urban poor are compared with
the rural population, for example in Bangladesh [34].
The factors underlying this urban versus rural difference include the better employment opportunities and
hence higher income among the urban population,
better access to processed foods and animal-source
foods (greater availability, affordability, and participation in the cash economy), greater proximity to healthcare services, and higher education levels [14, 27, 28].
Parental education

Several cross-sectional studies in a wide variety of

contexts have found a relationship between higher
maternal education and better child nutritional status
[35]. Maternal education is usually an indicator of the
highest level of schooling that a childs mother has
reached, which may have been up to 25 years prior to
giving birth to the particular child. Maternal education can be related to several things that can positively
influence child nutrition, including income-earning
potential, a later age at marriage and first pregnancy
and therefore higher birthweight of the child, empowerment and bargaining power within the family for
resources and prioritizing childrens nutrition and
healthcare, and knowledge and aptitude to act on new
information related to nutrition and health. Maternal
education can also be a proxy for paternal education
and income-earning potential [3639]. The combination of female literacy and urbanization in developing and emerging economies also increases womens

income, empowerment, and control over resources,

which can contribute to better child nutrition.
All of the above factorspurchasing power, urbanization, modernization of food systems, and increased
maternal as well as paternal educationthat increase
dietary diversity and thus, by improving nutrient
intake, contribute to reducing stunting prevalence, are
rapidly increasing in Southeast Asia.

Reducing the risk of stunting, targeting

different groups
As the example from Indonesia in figure 4 shows, the
prevalence of stunting varies across socioeconomic
groups, from 43.1% in the lowest wealth quintile to
24.1% in the highest wealth quintile. Similarly, over
70% of stunted and wasted children under 5 years
old live in middle-income countries, with the largest
number living in lower-middle-income countries [7].
This indicates inequality of access to economic development and a more nutritious diet during the critical
window of opportunity, but it also shows that although
the prevalence of stunting is higher among the poor, the
wealthier are also affected. The fact that stunting occurs
in different socioeconomic groups means that different
approaches can be used to improve nutrition among
these groups. Furthermore, among the poorer quintiles
of the population, disease-related issues, such as poor
environmental hygiene and limited access to preventive health services, are also still important causes
of undernutrition, in addition to diet-related causes.
Among them, both aspects need to be addressed
simultaneously, i.e., improving nutrient intake as well
as improving environmental hygiene (especially safe
drinking water and reduced environmental pollution)
and health education.
The Cost of the Diet (CoD) analysis in Indonesia
reported in the paper by Baldi et al. in this Supplement
illustrates how the prevalence of stunting is considerably higher in West Timor, where few households can
afford a nutritious diet, than in urban Surabaya, where
a much greater proportion can afford a nutritious diet
[25]. The households in urban Surabaya have more
spending power, and the availability of nutritious foods
for the general population, including women of reproductive age, and special nutritious foods for young
children, such as instant, fortified complementary
foods, is greater. However, the fact that nutritious foods
are more available does not automatically mean that
children in households that can afford these foods consume them, and if they do, it may not be in adequate
amounts. The situation in West Timor is very different.
First of all, fewer nutrient-dense foods are available;
secondly, they cost more because of the higher costs
to transport them from where they are produced; and
thirdly, household purchasing power is much less, and

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M. W. Bloem et al.

in addition to that, disease-related causes are still more

important in this population as well.
Role for the private sector

In both situations described above, i.e., one where most

people can afford more nutritious foods (Surabaya)
and another where most people cannot afford them
and where their availability is also less (West Timor),
fortified processed foods can make an important contribution to improving nutrient intake by pregnant and
lactating mothers and children aged 6 to 23 months.
However, the way in which people in these two situations can access such foods is different.
Figure 4 shows that stunting prevalence decreased
from 2007 to 2010 among Indonesias wealth quintiles
3, 4, and 5, with the largest decrease observed among
the richest, who consume the most varied diet with a
greater share of processed foods, manufactured and
marketed by the private sector. This indicates that
the households in these quintiles still need further
improvement of dietary quality in order to better meet
the nutrient requirements of their most vulnerable
members, which requires further increased availability
and accessibility of nutritious complementary foods
and awareness about their benefits. Households in the
3rd and 4th quintiles, as opposed to the wealthiest 5th
quintile, may also require improved access through
lower prices and/or greater availability in the areas
where they live.
Targeting of these higher quintiles with processed
nutritious foods and their marketing can be done by
the private sector. For these groups, the role of the
public sector is to set standards on nutritional value
and safety for such products and to increase consumer
awareness about healthy and nutritious diets.

or they can provide vouchers to obtain these products

from local stores that also sell the same products to
other customers. In the case of distribution using a
voucher system, marketing and packaging of products
could be the same as for the consumers who purchase
the products. Also, the requirement for food standards
and raising consumer awareness about healthy, nutritious foods would be the same, irrespective of which
consumer group is targeted.
The fact that the food system in Southeast Asia
already includes manufactured, fortified foods, and that
a sizeable proportion of the population already buys
such products, can be built upon to further increase
availability, lower cost, and improve nutritional quality
of foods, particularly targeting pregnant and lactating women as well as children 6 to 23 months of age.
Depending on socioeconomic status, consumers can
access such foods through existing commercial channels, or they can get access through vouchers that are
distributed by social safety net programs targeting the
poorest. Such a model of distributing vouchers for
specific foods through social safety nets and redeeming them at retail outlets requires a good, preferably
electronic, registration system for the social safety net
program and a good collaboration with manufacturers
of specific products and retail outlets.
ASEAN can play a supporting role in improving
access to nutritious foods for specific target groups by
setting standards for special nutritious products and
supporting cross-border trade, and by facilitating the
sharing of experiences with development and implementation of strategies that provide access to these
foods to consumer groups with a different socioeconomic status. The Business Network of SUN, which
aims to forge effective publicprivate partnerships for
the prevention of undernutrition, can also support the
piloting of such approaches.

Role of the public sector

The stunting prevalence among the lowest quintile

shown in figure 4 increased, whereas that in the
second quintile remained the same. This means that
the households in these poorest quintiles are not yet
able to afford adequately nutritious diets for their
pregnant and lactating women and young children,
while their need for an increased intake of nutritious
foods is greater than that of people in the wealthier
quintiles. They would thus benefit from the same
processed nutritious foods that are marketed to the
higher-income quintiles but would require public
sector support to be able to access them.
A good public sector distribution channel for such
special nutritious products would be social safety net
programs, which already support poor households
with cash and/or subsidized foods, such as rice for
the poor (Raskin) in Indonesia. Those programs can
either provide such special nutritious products in kind,

Conclusions and recommendations

The major pathway for further reducing stunting
prevalence in Southeast Asia is through better meeting
nutrient requirements from an increasingly diverse
diet, including processed, fortified foods for pregnant
and lactating women and children 6 to 23 months
of age.
The modernization of food systems, increased purchasing power, urbanization, and increased maternal
and paternal education levels in Southeast Asia increase
availability of and access to more nutrient-dense diets,
which are required for preventing undernutrition.
These developments, including increasing enrolment
in secondary school to increase the age at marriage of
adolescent girls, should continue.
In order to accelerate the reduction of stunting in
Southeast Asia, availability of and access to nutritious

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Key strategies to further reduce stunting in Southeast Asia

products should be increased by collaboration between

the private and the public sector, and ASEAN can play
a facilitating role.
The private sector can produce and market special

nutritious foods, while the public sector sets standards,

promotes healthy food choices, and ensures access to
special nutritious foods for the poorest, for example
through social safety net programs.

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