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Efficacy Of Eel Cookies On Improving Nutritional Status Of Pregnant Women With Chronic Energy Defifiency

A high prevalence chronic energy deficiency (CED) in pregnant women exist in Indonesia, which approximately 16.2%. The government had made various efforts to eliminate CED in pregnant women. Therefore, our study aimed to analyze the efficacy of eel cookies on improving nutritional status of pregnant women with CED risk. An experiment with a prepost design of 36 pregnant women with risk of CED in Ciletuh, Sukabumi was carried out for 30 days. Pregnant women in intervention group were given eel cookies, while control group were given cookies without eel. At the beginning and end of the study, MUAC were measured and food intake was assessed through a 24 hour recall. The research data was analysed using t-test, Mann-Whitney test and chi square. Significant difference in body weight between intervention and control groups was not found (p > 0.05). The mean bodyweight in intervention group after intervention (48.5) was higher than in control group (48.3). The Mean bodyweight and MUAC in the two groups before and after intervention also did not show a significant difference (p> 0.05). The risk of CED in pregnant women who received eel cookies were lower compared to the control group. Consumption of eel cookies can reduce CED risk in pregnant women by 35%, while cookies without eel only reduce the risk by 29.4%. Eel cookies had higher efficacy compared to cookies without eel on reducing CED risk in pregnant women.


INTRODUCTION
Chronic energy deficiency (CED) in pregnancy were one of the malnutrition issues during pregnancy which directly affect the mother, the fetus, the puerperium period, and the born baby (Worttesley et al, 2016). Malnutrition during pregnancy has undoubtedly led to stunted fetal growth, low birth weight, and fetal and maternal mortality (Black et al, 2013;Bhuta et al, 2013;Victora et al, 2012). Pregnant women with CED were However, the RUTF program has not been able to reduce the incidence of CED in pregnant women. The prevalence of pregnant women with CED in 2016 was higher (16.6%) than in 2015 (13.3%). Increased prevalence of CED in pregnancy showed that nutritional problems in pregnancy need a preventive intervention (Ministry of Health, 2015). Additionally, the amount of energy and protein adequacy in pregnant women is still far from the Nutrient Adequacy Ratio (NAR) for pregnant women.
The results of a preliminary study conducted in Ciwaru Village, Ciemas Subdistrict, Sukabumi District, on 39 pregnant women indicated that 28/39 or 71.8% of them had nutritional problems such as anemia and CED.
It is necessary to develop the diversification of RTFU types for pregnant women with CED as an effort to improve the nutritional status of pregnant women.
Several studies have shown that adequate supplementary food for pregnant women can overcome malnutrition problems in pregnancy (Pastuty et al, 2018;Hernawati and Kartika, 2018). A study conducted in Mali has met energy, protein, fat and fiber requirements of malnourished pregnant women by providing RUTF (Bechman et al, 2015). The RUTF contents included beans, millet, barley koji (containing a-amylase and other ingredients).
Large amount of marine products available in Indonesia, such as eel. Eel could be found easily in the Sukabumi Districts and could be a source of animal protein which rich in amino acids and fats that are good for health (Nafsiyah et al, 2018). Eel is a food source that has a high nutrient content (Widyasari et al, 2014). This study conducted in the beach area of Sukabumi District, which had eel as a local food. Eel flour could be used to make eel cookies to increase food intake and improve nutritional status in pregnant women with CED (Fahmi et al, 2010;Giango, 2016).
The basic ingredients of the eel cookies was flour of eel bone as a source of protein and fat and corn flour as a source of carbohydrates (Istinganah et al, 2016). Aside from being a source of carbohydrates, the corn flour also has a high provitamin A and fiber that can be used as ingredient for making cookies (Hardiyanti et al, 2016).
Eel cookies were expected to be an alternative supplementary food which could be used in the RUTF program for pregnant women with CED. This study aimed to analyze the efficacy of eel cookies on improving nutritional status (MUAC) in pregnant women with CED risk.  Analysis of energy intake unable to show a significant difference of energy intake at the end of the intervention. The energy intake in both groups were homogeneous. Energy intake from both cookies showed no significant difference (p> 0.05). The mean difference in improvement of energy intake at the beginning and end of the intervention in both groups showed a significant difference (p = 0.035). The mean difference in improvement of energy intake in the intervention group was higher than in the control group, which were 9.3 and -2.22 respectively. These results indicate that the energy intake from the cookies at the end of the intervention is related to the daily energy intake ratio of pregnant women. Difference in protein intake from the cookies at the end of the intervention in both groups was insignificant (p> 0.05). The mean difference in protein intake at the beginning and end of the intervention in both groups also did not show a significant difference (p = 0.692). This proves that the intake of protein from the cookies was not related and did not have significance with the daily protein intake of pregnant women.

*Paired t test *** Mann Whitney
Reduction of CED risk in pregnant women who received eel cookies was higher compared to pregnant women who received cookies without eel. Lower CED risk in intervention group was seen, which was 33.3 % compared to 44.4% in control group.

Picture 1. CED Risk Prevalence Graph Before and After Intervention
The prevalence of CED risk reduction in pregnant women who consumed eel cookies was higher than those who received cookies without eel. The effectiveness value is the success rate of the intervention, in this intervention was giving eel cookies.
The efficacy value in both groups was 53%. In the intervention group 66.7% of pregnant women who received eel cookies were not at risk of CED, while in the control group there were 55.6% who did not have CED risk. The effectiveness value calculated by: -% Effectiveness = % Efficacy x %pregnant women who did not have CED risk in each group -% Effectiveness of intervention group was 53% x 66,7% = 35%.
Although there were no significant differences statistically in bodyweight and MUAC changes in both groups, giving eel cookies could reduce CED risk in pregnant women by 35%, while giving cookies without eel reduce 29.4% of CED risk.

Subject Characteristics
Some of the subjects' age in this study were under 20 years. Pregnancy at a young age had a substantial risk for CED development compared to pregnancy at over 20 years of age. This was in accordance with a research conducted by Kusparlina who stated that one of the factors which influence CED risk was pregnancy before 20 years of age (Kusparlina, 2016 showed that the incidence of CED among housewives was 5.55 times higher (Kartikasari and Mustika, 2013).
As the gestation age, the appetite of pregnant women is improving. Thus, the RUTF intervention in the form of eel cookies was expected to have a considerable effect on the pregnant women's health. Trimester 2 and trimester 3 pregnancy required adequate nutrition for adaption to metabolic changes that occur during pregnancy (Fried et al, 2017).
The energy intake requirements in pregnancy was utilized for maternal and fetal metabolism, as well as fetal growth (Most et al, 2019). The requirements depend on the body size of the pregnant women, physical activity category and physiological requirements in each trimester (Most et al, 2019). Increased needs due to metabolic changes required a balance intake of macro and micronutrient which fulfilled the nutrient adequacy ratio to maintain the balance of hormonal changes that occur during pregnancy (Godfrey et al, 2017).

Energy and Protein Intake
Nutritional intake during pregnancy was strongly affected by pregnancy hormones, fetal development and increased maternal activity. Pregnancy was a condition which was prone to malnutrition. Balanced nutrition depends on eating habits and the amount of food consumed to support fetal growth, development, and health.
Additional energy from the cookies provided were 500 kcal per 100 grams which were important to fulfil daily calories requirements by 25% and were expected to compensate a 15% increase in metabolism during pregnancy to support metabolism and physiology during pregnancy. The results of this study indicate that there was an increase in energy intake in pregnant women with CED risk after receiving cookies in both groups.
Eel had a dense nutrient content, including micro nutrients such as zinc to improve immunity and appetite as well as contribute positively to energy intake changes.
The increased daily energy intake in pregnant women was not statistically significant because each group was given similar calorie intake. The difference was also insignificant for increasing protein intake in both groups.
Therefore, it could be concluded that supplementary food for pregnant women with energy amount of 500 kcal could increase energy intake by 25% of the total daily requirements. These results were in line with WHO recommendations and guidelines for supplementary food in CED women, that balanced energy food could improve daily food intake of pregnant women (Kemenkes, 2015;WHO, 2016).

Bodyweight and MUAC Changes
The results of this study indicated that pregnant women after receiving RUTF for 30 days in the form of eel cookies were not significantly different in changing bodyweight from the women who received cookies without eel. The average increase of body weight in the intervention group was 3.9 kg, while the control group was 4 kg. The changes of bodyweight in this study were higher than in the research conducted by Amerta, which increase bodyweight of pregnant women approximately 4.48 kg after receiving RUTF for 3 months (Amareta, 2016 Omega 3 and omega 6 could not be synthesized in human body, therefore we need a marine food source which contain high omega 3 and 6 (Swanson et al, 2012). EPA and DHA supplementation during pregnancy will improve fetal development (Ramakrishnan et al, 2010;Swanson, 2012).
Maternal nutritional guidelines always emphasize on diet including adequate calorie and protein intake, but recently fatty acids had also been considered important (Ramakrishnan et al, 2010). Nutritional deficiencies in pregnant women were caused by inadequate energy intake including protein, essential fatty acids (especially omega 3 fatty acids), iron, folate, and other micronutrients during pregnancy.
The results of a systematic review showed that the quality of maternal food intake during pregnancy had a positive association with fetal development (Borge et al, 2017). The association between maternal and fetal nutrition was complex, and influenced by many factors such as biological, socioeconomic, and demographic as well as population variations (Abu-Saad and Fraser, 2010). Understanding the relationship between maternal and fetal nutrition could provide a basis for nutritional intervention development which led to birth outcomes and long-term quality of life improvements, while reducing the maternal and fetal mortality, morbidity, as well as health costs (Abu-Saad and Fraser, 2010). This opinion is supported by the Cochrane study which identified balanced protein energy supplementation during pregnancy that could significantly improve fetal birth weight and length (Ota et al, 2015).

CONCLUSION
Eel cookies is more effective than cookies without eel, although the results of statistical analysis did not show significant difference in bodyweight and MUAC between intervention and control groups.
Eel cookies could be an alternative of RUTF for pregnant women with CED risk. Sukabumi District is expected to provide eel cookies as RUTF for pregnant women with CED because they were made of local food source which were widely available locally.