Evaluasi Nilai Gizi Ready-to-Use Therapeutic Food (RUTF) Berbahan Susu, Polong-Polongan, dan Ikan

Abstract

Severe Acute Malnutrition (SAM) pada balita merupakan salah satu masalah kesehatan masyarakat yang masih dihadapi di berbagai negara terutama negara dengan pendapatan rendah dan menengah. Tingkat keparahan kondisi ini berhubungan dengan meningkatnya risiko kematian dan penyakit infeksi pada balita. Data Riskesdas tahun 2018 menunjukkan sebanyak 17,7% balita di Indonesia mengalami gizi buruk dan gizi kurang (Kemenkes 2018). Pemberian makanan padat zat gizi seperti ready-to-use therapeutic food (RUTF) dilakukan sebagai salah satu upaya penanganan gizi buruk pada balita yang berada pada fase rehabilitasi. Oleh karena itu, RUTF memiliki persyaratan standar zat gizi yang harus dipenuhi (Joint FAO/WHO Codex Alimentarius Comission 2019). Zat gizi seperti protein, berperan pada proses pembentukan jaringan serta peningkatan berat badan pada balita SAM (Oakley et al. 2010; Manary 2013). Mineral seperti zat besi (Fe) dan seng (Zn) perlu diperhatikan dalam RUTF karena defisiensinya sering terjadi pada balita SAM (Akomo et al. 2019). Selain jumlah zat gizi, kualitas zat gizi juga perlu diperhatikan dalam produk RUTF karena jumlah zat gizi yang tersedia pada pangan belum tentu dapat diserap seluruhnya oleh tubuh. Pengukuran kualitas zat gizi dapat dilakukan dengan metode in vitro, yang merupakan metode alternatif dan memiliki korelasi yang baik dengan data in vivo. Pengembangan RUTF mulai dilakukan di berbagai negara, termasuk di Indonesia. Rimbawan et al. pada tahun 2020 (data belum dipublikasi) mengembangkan RUTF berbentuk wafer roll berisi pasta menggunakan kombinasi beebrapa protein, yaitu susu (RUTF Susu), kedelai dan kacang hijau (RUTF Polong-Polongan), tepung ikan lele (RUTF Ikan), dan kombinasi kedelai serta tepung ikan lele (RUTF Kedelai-Ikan). Untuk dapat memastikan formula RUTF sesuai dengan kebutuhan balita SAM, perlu dilakukan analisis terhadap zat gizi maupun kualitas gizinya. Secara umum tujuan dari penelitian ini adalah melakukan evaluasi nilai gizi RUTF untuk mengetahui kesesuaian formula RUTF dengan spesifikasi standar sebelum RUTF diintervensikan kepada balita. Tujuan penelitian ini secara khusus yaitu menganalisis kandungan energi, protein, lemak, karbohidrat, serat pangan, zat besi, dan seng pada keempat formula RUTF serta membandingkannya dengan spesifikasi standar RUTF (Joint FAO/WHO Codex Alimentarius Comission 2019). Selain itu, analisis terhadap bioaksesibilitas mineral besi (Fe) dan seng (Zn) serta daya cerna protein in vitro juga dlakukan untuk mengevalusi kualitas zat gizi tersebut. Analisis terhadap asam amino juga dilakukan untuk menetahui skor kimia serta menentukan protein digestibility corrected amino acid score (PDCAAS) in vitro pada RUTF terpilih. Keempat RUTF dihitung kontribusi per kemasan terhadap Angka Kecukupan Gizi Balita (AKG) serta dilakukan perhitungan jumlah RUTF yang perlu dikonsumsi selama satu hari. Penelitian ini menggunakan desain eksperimental di laboratorium dengan rancangan acak lengkap yang terdiri dari tiga taraf dan tiga ulangan. Taraf berupa jenis formula RUTF yang diperoleh dari penelitian Rimbawan et al. (2020), yaitu RUTF Susu, RUTF Polong-Polongan, RUTF Ikan, dan RUTF Kedelai-Ikan. Penentuan formula terpilih dilakukan berdasarkan kandungan zat gizi RUTF serta bioaksesibilitas mineral dan protein in vitro. Hasil analisis menunjukkan bahwa secara umum keempat formula memenuhi standar zat gizi per 100 g produk dengan kadar air sebesar 1,92–2,23%, lemak sebesar 29,90–31,79 g, protein sebesar 12,96–14,85 g, karbohidrat sebesar 42,52–45,36 g, serat pangan sebesar 4,58–4,87%, energi sebesar 514– 524 kkal, Fe sebesar 9,48–11,63 mg, dan Zn sebesar 9,73–10,70 mg. Formula RUTF Polong-Polongan memiliki kandungan protein terendah dan sedikit berada di batas standar minimal sebesar 13%. Kandungan energi terendah beda pada RUTF Ikan yang nilainya sedikit berada di bawah peryaratan minimal 520 kkal. RUTF Susu memiliki kandungan Fe terendah dan sedikit berada di bawah standar minimal 10 mg. Keempat RUTF memiliki biokasesibilitas Fe dan Zn lebih dari 50% dan disertai dengan daya cerna protein in vitro yang tinggi, yaitu antara 95,32–99,5% dengan nilai minimal pada RUTF Polong-Polongan dan maksimal pada RUTF Susu. Berdasarkan analisis kandungan dan kualitas zat gizi, RUTF Kedelai-Ikan dan RUTF Susu ditentukan sebagai formula terpilih dan memiliki skor PDCAAS in vitro sebesar masing-masing 94±1,67 dan 71±0,6 dengan asam amino pembatas lisin. RUTF Kedelai-Ikan memiliki PDCAAS in vitro yang melebihi standar minimal 90. Keempat RUTF memberikan kontribusi energi lebih dari 30% terhadap pemenuhan kebutuhan energi balita sehat usia 1–3 tahun dan 4–6 tahun. Selain itu, keempat RUTF juga berkontribusi terhadap lebih dari 50% kebutuhan protein dan lemak, lebih dari 20% kebutuhan karbohidrat dan serat pangan, serta 2–3 kali lipat kebutuhan Fe dan Zn. Untuk dapat memenuhi kebutuhan energi sebesar 175 kkal/kgBB/hari, balita SAM perlu mengonsumsi RUTF wafer roll berisi pasta sebanyak 7–17 buah untuk berat badan 3–7 kg dan lebih dari 24 buah untuk berat badan di atas 10 kg. Keempat formula RUTF berpotensi untuk dikembangkan lebih lanjut sebagai makanan terapi bagi balita SAM dengan melakukan beberapa upaya perbaikan, yaitu pengurangan penggunaan serealia dan polong-polongan, penambahan protein hewan atau isolat protein kedelai untuk RUTF Polong-Polongan, penggunaan whey protein concentrate untuk RUTF Susu, serta pengolahan ikan menggunakan kunyit atau kelapa untuk meminimalisasi karakteristik amis. Pengawasan terhadap pemberian RUTF perlu dilakukan agar jumlah yang dikonsumsi dapat memenuhi kebutuhan balita SAM. Selain itu, karena tingginya kandungan gizi RUTF, konsumsi selain pada balita SAM dapat menimbulkan risiko kelebihan zat gizi.

Severe Acute Malnutrition (SAM) is one of public health problem that becomes prevalent among under-five-aged children, particularly in low and middle-incomed countries. The severity of this condition is associated with an increased risk of death and susceptibility to disease. According to Indonesian Ministry of Health (2018), around 17,7% of Indonesian children had severe and moderate acute malnutritions, which is exceeding the 17% of maximum target. The home-based therapy by provisioning a nutrient-densed therapeutic food, called ready-to-use therapeutic food (RUTF) was initiated during the rehabilitation phase of severely acute malnourished children that had no clinical complications and showed good appetite. Therefore, to provide adequate nutrients for children with SAM, RUTF products have to comply with nutritional specification standards (Joint FAO/WHO Codex Alimentarius Comission 2019). Protein needs to be considered in RUTF product because the important roles in recovery process of SAM children due to its function as a building block for tissue formation and the ability to accelerate weight gain (Oakley et al. 2010; Manary 2013). Along with protein, minerals such as Fe and Zn also need to be considered because the deficiencies are prevalent among SAM children as well as in Indonesia (Akomo et al. 2019). Other than quantity, nutritional quality also needs to be considered since the amount of nutrients ingested from food not necessarily be fully absorbed by human’s body. The determination of nutritional quality could be performed by in vitro method that has a good correlation with in vivo data (Minekus et al. 2014). Several countries had developed RUTF products using locally available ingredients, including Indonesia. Rimbawan et al. in 2020 (data not yet published) carried out the study that developed several RUTF formulas, combining a range of protein sources such as milk (RUTF milk), soy and mungbean (RUTF Legumes), fish (RUTF Fish), and combination of soy and fish (RUTF Soy-Fish). To ensure the compliance of RUTF with the standard, the nutritional evaluation of RUTF should be conducted. The main purpose of this study was to evaluate the nutritional value of RUTF in order to compare the product with nutritional standard before it is consumed by children with SAM. The specific purposes of this study were to analyze the energy, protein, fat, carbohydrate, dietary fiber, iron, and zinc contents in the four RUTF formulas and compare them with the RUTF standard specifications (Joint FAO/WHO Codex Alimentarius Comission 2019). In addition, the analysis of in vitro bioaccessibility of iron and zinc as well as protein digestibility were also carried out to evaluate the quality of these nutrients. Amino acid analysis of the selected RUTF was also carried out to determine the chemical score and the in vitro protein digestibility corrected amino acid score (PDCAAS). The four RUTFs were calculated for the nutritional contribution per package applied for Recommended Daily Allowance (RDA) among children aged 1–3 and 4–6 years in Indonesia. The quantity of RUTFs that need to be consumed by children with SAM a day was also calculated. This study used an experimental design in the laboratory with a completely randomized design consisting of three levels and three replications. The level is a type of RUTF formula obtained from the research of Rimbawan et al. (2020), namely RUTF Milk, RUTF Legumes, RUTF Fish, and RUTF Soybean-Fish. The analysis were performed to determine the nutritional compositions, in vitro mineral bioaccessibility, and in vitro protein digestibility. The results of the analysis showed that generally the four formulas met the nutritional standards per 100 g of product with moisture content of 1,92–2,23%, fat of 29,90–31,79 g, protein of 12,96–14,85 g, carbohydrates of 42,52–45,36 g, dietary fiber of 4,58–4,87%, total energy of 514–524 kcal, Fe of 9,48–11,63 mg, and Zn of 9,73–10,70 mg. The Legume RUTF had the lowest protein content and was slightly under the minimum requirement of 13%. The lowest energy content was derived from Fish RUTF that showed slightly lower value to the minimum of 520 kcal. RUTF Milk had the lowest Fe and Zn content that demonstrated slightly lower values than the standard minimum of 10 mg and 11 mg, respectively. The four RUTFs had more than 50% Fe and Zn in vitro bioaccessibility and followed by high in vitro protein digestibility, which were between 95,32–99,5% with a minimum value in the Legumes RUTF and a maximum value in the Milk RUTF. Based on the analysis of nutrient contents and qualities, the Soy-Fish RUTF and Milk RUTF were determined as the selected formulas and had in vitro PDCAAS scores of 94±1,67 and 71±0,6, respectively, with the limiting amino acid of lysine. The Soy-Fish RUTF had an in vitro PDCAAS that exceeded the minimum standard of 90. The four RUTFs contributed more than 30% of energy requirement for healthy children aged 1–3 years and 4–6 years. In addition, the four RUTFs also contributed to more than 50% of the requirements for protein and fat, more than 20% for carbohydrates and dietary fiber, and 2–3 times of requirements for Fe and Zn. In order to fulfill the energy requirement of 175 kcal/kg/day, SAM children needs to consume 7–17 pieces of RUTF wafer roll filled with cream paste for a body weight of 3–7 kg and more than 24 pieces for body weight above 10 kg. The four RUTF formulas potentially could be further develop as therapeutic food for children with SAM by improving the formulas, such as reducing the use of cereals and legumes, adding animal-based protein or soy protein isolate for RUTF Legumes, using whey protein concentrate for RUTF Milk, and pre-treat fish, using turmeric or coconut to minimize the fishy characteristics. Supervision of the provision of RUTF needs to be carried out so that the amount consumed can meet the nutritional requirements of children with SAM. In addition, due to the high nutritional content of RUTF, consumption by other than children with SAM group without any supervision, could increase a risk of excessive nutrients intake.