Hrev_master Healthcare in Low-resource Settings 2024; volume 12(s1):13042 The comparison of carbohydrates, fibers, and immunoglobulin-A levels in feces against stunting children in Tuban Regency Rivan Virlando Suryadinata,1 Heru Wijono,1 Firstylo Valiant Putra Sanwersko,1 Yosafat Elohimio Susanto,1 Amelia Lorensia2 1Faculty of Medicine, Universitas Surabaya, Surabaya, East Java; 2Faculty of Pharmacy, Universitas Surabaya, Surabaya, East Java, Indonesia Abstract Stunting in children under five years old is a major health problem in Indonesia. A compromised immune system in stunted children increases the risk of infection which has an impact on morbidity and mortality. Moreover, food intake is one of the caus- es of decreased immunity, where carbohydrate, fiber, and immunoglobulin-A levels in the intestine are related to the immu- nity of children under five years old. The assessment of feces con- tent can provide an overview of carbohydrates, fiber, and immunoglobulin-A levels in the intestine. Therefore, this study aimed to determine the comparison of carbohydrate, fiber, and immunoglobulin-A levels in feces for stunted children. An obser- vational method with a case-control design was used, and it was conducted in Tuban Regency from May to July 2023. Forty stool samples were obtained from 20 stunted children and 20 non-stunt- ed children who were tested for carbohydrates, fiber, and immunoglobulin-A. Subsequently, the data were analyzed with a comparison test to determine the differences between the two groups. The results showed that carbohydrate and immunoglobu- lin-A levels were higher, while fiber levels in feces were lower in stunted children (p≥0.05). It was concluded that there were differ- ences in levels of carbohydrates, fiber, and immunoglobulin-A in the intestines of stunted children. Introduction The problem of malnutrition in children under five years old is a global health concern, with developing countries recording over 50% of death cases. Malnutrition in this age group can be prevented through treatment and intervention strategies.1 Even though there has been a reduction in the prevalence of malnutri- tion, the decline has not been significant. In low-income commu- nities, the risk of mortality before the age of 20 is doubled, similar to the risk of stunting children due to chronic malnutrition.2 Stunting is a chronic nutritional problem attributed to inadequate nutrient intake over a long period, resulting in impaired growth in children. Globally, the prevalence of stunting among children under five is 21.3%.3 with Africa recording a prevalence of 30.9% in 2015. More than 155 million children under five suffer from stunting globally, with over 1 million deaths and a third experienc- ing Disability Adjusted Life Years (DALYS).4 Asian regions recorded 83.6 million cases, with the highest proportion originat- ing from South Asia (58.7%), and Indonesia (27.67%) in 2019.5 Stunting is an indicator for determining the well-being of chil- dren, reflecting environmental and social inequalities. Various risk factors contribute to stunting, including parental (physical condi- tion and nutritional status of the mother during pregnancy, parental education level, and socio-economic status), child (genet- ic, anthropometric, infection, food intake during infancy, gender, and age), environment (hygiene, sanitation, drinking water sources, culture, and beliefs) among others.6 Stunting process often begins during pregnancy, influenced by the mother’s dietary history during gestation.7 The impacts of disease on stunted chil- dren include inflammation, disruption of the leptin hormone, and increased glucocorticoids. These factors can trigger neurological development disorders, neurogenesis, and apoptosis, affecting brain areas related to cognition and memory in children.8 Others may include digestive tract disorders in the form of intestinal inflammation. These lead to hampered nutrients absorption, fur- ther worsening the condition of stunted children. Intestinal disor- ders can also compromise the immune system, facilitating micro- bial invasion, diseases, and systemic inflammation.9 Intestinal inflammation can impact children nutritional status through impaired absorption of carbohydrates and proteins. It also disrupts the intestinal mucosa and microbial metabolic activity, which is essential for preventing the entry of pathogens.10 Microbiota in the food tract plays a significant role in children health, such as increasing metabolism and immunology. This con- dition is influenced by various factors, including food intake, par- ticularly fiber. Fiber, a type of polymeric carbohydrate found in food, cannot be absorbed and undergoes fermentation, thereby affecting the bacterial community and microbial metabolic activi- ty.11 Immunoglobulin A (Ig A), secreted by the mucous membrane lining the gastrointestinal tract plays a role in protecting or provid- ing immunity in the digestive tract. Adequate IgA production enhances gut-associated lymphoid tissue (GALT) and functions as a mechanical barrier in the digestive tract.12 Significance for public health Stunting events tend to have a negative impact on children development. Various risks of health and intellectual disorders can also cause a decline in the qual- ity of human resources in a country. Decreased digestive tract function is one of the factors contributing to immune system disorders in stunted children, which can trigger the emergence of diseases and decreased absorption and metabolism from the GI Tract. This study seeks to analyze and compare the levels of car- bohydrates, fibre, and immunoglobulin-A in the faeces of stunted children, aiming to provide valuable insights into potential dietary and immune factors con- tributing to stunting. [page 62] [Healthcare in Low-resource Settings 2024;12(s1):13042] Non -co mmerc ial us e o nly Stunting in children can lead to various vulnerabilities in the body, increasing the risk of mortality. Genetic, racial, and ethnic differences, as well as the provision of food, also tend to influence the risk of stunting.13 Different interventions, including nutritional support and education, are required for each stunted child in vari- ous regions. Therefore, assessing the levels of carbohydrates, fiber, and immunoglobulin-A in feces of stunted children in Tuban Regency is necessary to determine differences between the groups. Materials and Methods This study used an observational with a case-control method and was conducted in Tuban Regency from May to July 2023. Research approval was issued by Tuban Regency One-Stop Investment and Integrated Services Service (No.070/298/1.S/414. 111.3/2023). Furthermore, a non-random purposive sampling method was used. Respondents were 20 stunting and 20 non-stunt- ing children residing in Tuban Regency, East Java, who met the inclusion criteria (aged 2-5 years, free from autoimmune or con- genital diseases related to GI Tract, and not suffering from diseases affecting digestion during the study period such as gastroenteritis, hepatobiliary, parasites, or worms) and exclusion criteria (fecal samples showing abnormal characteristics such as changes in color, texture, and odor). Children who agreed to participate were accompanied by vil- lage cadres to receive further information about the study and to sign informed consent. Height/body length measurements were taken before fecal collection, and mothers were educated on the proper collection procedure, including separation from urine by urinating first. Fecal samples were collected in plastic wrap and transferred to clean, dry, and tightly closed pots using a stick or spoon. Each pot was labeled, stored in an ice box at temperatures of 4-8°C, and transported to the nutrition laboratory of the Faculty of Public Health, Airlangga University for analysis. Carbohydrate levels were examined using the Luff School test, fiber levels through gravimetric test, and Immunoglobulin-A levels using enzyme-linked immunosorbent assay (ELISA) method. The obtained data were analyzed using a comparison test. Normality test was first carried out to assess data distribution, respectively followed by homogeneity, and Independent T-test for comparison. Mann-Whitney test can be carried out when data are not normally distributed or heterogeneous. Result and Discussion Characteristics of respondents included gender, history of exclusive breastfeeding, history of diarrhea frequency each year, and type of additional food intake. Respondents were 20 stunting and 20 non-stunting children residing in Tuban Regency, East Java. Based on Table 1, the majority were female, namely stunting (60%) and non-stunting (65%) children. Furthermore, there were 85% exclusive breastfeeding non-stunting children. Both groups demonstrated a similar history of diarrhea frequency of once per year (40%), with porridge being the most common food intake. Stunted children were affected by various factors such as socio-economics, environmental conditions, and behavior. Gender differences in the risk of stunting varied significantly between regions, with several studies showing no effect due to wrong par- enting patterns.14 A mother’s behavior in complying with exclusive breastfeeding had been proven to be associated with an increased risk of stunting. Examples of poor food intake for children include micronutrient content, low food diversity, and wrong feeding pat- terns in terms of timing, consistency, and quantity. Infant nutrition is crucial for the health and development of children.15 Optimal breastfeeding and provision of healthy and appropriate comple- mentary foods to babies until 2 years can increase immunity fac- tors.16 Diarrhea is known to be a complication of stunting and envi- ronmental conditions, affecting approximately 13.5%. Sampling from a single population tends to have similarities in terms of envi- ronmental conditions and sanitation hygiene.17 A significant rela- tionship was found between children who received complementary foods and the risk of stunting. However, the additional food in question was not solely based on the quantity or type of food pro- vided, but also on diversity, balance of macronutrients and micronutrients, as well as intake of vitamins and minerals. The most important period of a children growth is up to the age of 60 months when any slowdown can cause disruption.18 The results of fecal examination are presented in Table 2. The average carbohydrate content was ± SD-value of 11.39 ± 1.18 mg in feces of stunted children and 6.45 ± 1.17 mg for non-stunted. The average fiber content was ± SD-value of 5.28 ± 0.78% for stunted and 2.98 ± 0.73% for non-stunted. The average immunoglobulin-A level was ± SD-value of 31.47 ± 4.08 ng/mL for stunted and 12.94 ± 1.38 ng/mL for non-stunted. The absorption of carbohydrate macronutrients is influenced by starch, lactose, and sucrose consumed. Foods containing cellu- lose cannot be digested by the small intestine, while monosaccha- 4th International Nursing and Health Sciences Symposium Table 1. Distribution of respondents’ characteristics. Characteristics Stunting Non-Stunting Frequency % Frequency % Gender Male 8 40 7 35 Female 12 60 13 65 Exclusive breastfeeding Yes 5 25 17 85 No 15 75 3 15 History of frequency of diarrhoea 1x/year 8 40 8 40 2x/year 10 50 7 35 3x/year 1 5 4 20 Every drinking milk 1 5 1 5 Types of additional food intake Fine Porridge 14 70 15 75 Packaged Porridge 2 10 0 0 Family Food 4 20 5 25 [Healthcare in Low-resource Settings 2024;12(s1):13042] [page 63] Non -co mmerc ial us e o nly rides are absorbed more rapidly by the body. Digestion of carbohy- drates initiates in the mouth through the action of amylase enzyme, and continues further in the microvillus membrane. However, monosaccharides can be directly absorbed, and unabsorbed carbo- hydrates, such as cellulose, are fermented by bacteria in the large intestine and used for energy conversion. Excessive carbohydrate fermentation in malabsorption disorders can lead to bloating.19 Absorption disorders in stunted children are related to adaptation mechanisms to chronic calorie, protein, and environmental defi- ciencies, as well as the extent of malnutrition.20 Malnutrition con- tributes to a decrease in the secretion of pancreatic enzymes (lipase, trypsin, chymotrypsin, and amylase), atrophy of the villi in the intestine, changes in blood flow, and increased intestinal per- meability. This can result to a decrease in digestive enzymes and absorption function in the large intestine.21 Changes in the micro- biota of the digestive tract, thinning of the mucosal layer and intes- tinal wall, atrophy of the microvilli (brush border), and changes in mucosal cells lead to increased intestinal mucosal permeability, more than threefold, in stunted children.22 Consequently, this affects carbohydrate absorption, resulting in higher carbohydrate levels in feces of stunted children compared to non-stunted. Based on Table 3, data on carbohydrate, fiber, and immunoglobulin-A levels showed a normal distribution (p>0.05). In the homogeneity test, the homogeneous variables were carbohy- drates and fiber (p>0.05), while Immunoglobulin-A was heteroge- neous (p<0.05). Independent t-test was conducted to compare car- bohydrate and fiber variables, which showed significant differ- ences between the two groups (p> 0.05). Furthermore, immunoglobulin variable was assessed using Mann Whitney test, showing significant differences (p>0.05). The microbiota in humans comprises bacteria, fungi, archaea, protozoa, and viruses found in the digestive tract. It plays a crucial role in processing dietary fiber to release antioxidant or anti- inflammatory components. The breakdown of fiber by colonic microbiota can prevent various diseases, including digestive (coli- tis and infections) and metabolic disorders (diabetes, cardiovascu- lar disease, and obesity).23 Gut microbiota is related to digestion, absorption, and intestinal function. Stunting children experience changes in the composition of gut microbiota, leading to an imbal- ance or dysbiosis.24 This dysbiosis can be related to malnutrition and a decrease in essential amino acid levels in plasma. Furthermore, gut microbiota is essential in regulating body weight, particularly Short Chain Fatty Acid (SCFA) production. Changes in gut microbiota are also related to the pathophysiology of stunt- ing and can be detected before growth retardation occurs.25 Consumption of dietary fiber influences the microbial composition in the human gut and microbiome function, potentially leading to the development of chronic inflammatory diseases.26 The increase in fecal fiber levels in stunted children is attributed to the absence of microbiota in the digestive tract. Immunoglobulin (Ig) A contributed to host bacterial homeosta- sis in the intestine, which showed nutritional deficiency was asso- ciated with changes in the interaction between IgA and gut micro- biota.27 Chronic nutritional deficiency tends to alter IgA recogni- tion of the microbiota. Microbes bound to IgA in feces are signifi- cantly higher in stunted children. Stunting is associated with an increase in antibodies, leading to intestinal dysbiosis and inflam- mation. 28 IgA also functions as a mucosal antibody in the intestine. A substantial increase of IgA in stunted and non-stunted children should be considered due to the potential as a pathogen. 29 The chronic inflammatory process directly induces body inflammation and cell damage. 30 Therefore, increased Ig A levels are often observed in stunted children with infections and associated with a high risk of death. Conclusions In conclusion, carbohydrate and immunoglobulin-A levels were higher in feces of stunted children due to digestive disorders and inflammatory processes, while fiber levels were lower (p≤ 0.05). 4th International Nursing and Health Sciences Symposium [page 64] [Healthcare in Low-resource Settings 2024;12(s1):13042] Table 2. Results of children feces examination. Variable Average ± SD Maximum Minimum Carbohydrate (mg) Stunting 11.39 ± 1.18 13.02 8.99 Non-stunting 6.45 ± 1.17 8.12 4.18 Fiber (%) Stunting 5.28 ± 0.78 6.58 3.64 Non-stunting 2.98 ± 0.73 4.13 1.49 Immunoglobulin-A (ng/mL) Stunting 31.47 ± 4.08 39.90 25.92 Non-stunting 12.94 ± 1.38 15.02 11.04 Table 3. Difference test results in children feces. Variable Normality Test Homogeneity Test P-Value Carbohydrate (mg) Stunting 0.252 0.798 < 0.001 Non-stunting 0.359 Fiber (%) Stunting 0.525 0.645 < 0.001 Non-stunting 0.631 Immunoglobulin-A (ng/mL) Stunting 0.124 < 0.001 < 0.001 Non-stunting 0.053 Non -co mmerc ial us e o nly References 1. Joulaei H, Keshani P, Ashourpour M, et al. The prevalence of stunting among children and adolescents living in the Middle East and North Africa region (MENA): A systematic review and meta-analysis. J Glob Health 2021;11:04070. 2. Goldhagen JL, Shenoda S, Oberg C, et al.Rights, justice, and equity: a global agenda for child health and wellbeing. 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Ethics approval: research approval was issued by Tuban Regency One- Stop Investment and Integrated Services Service (No.070/298/1.S/414.111.3/2023). Conference presentation: part of this article was presented at the 4th International Nursing and Health Sciences Symposium, from 27th-28th of October 2023, Universitas Brawijaya, Malang, East Java Indonesia. Acknowledgement: the authors sincerely thank the Faculty of Medicine, Universitas Surabaya staff for their valuable assistance during this research. Received: 3 November 2023. Accepted: 8 June 2024. Early view: 10 September 2024. 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