Efficacy of Protein-Rich Soy Biscuits on Growth Parameters of Stunted Children in West Java, Indonesia: A Randomised Controlled Study

Efficacy of Protein-Rich Soy Biscuits on Growth Parameters of Stunted Children in West Java, Indonesia: A Randomised Controlled Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy of Protein-Rich Soy Biscuits on Growth Parameters of Stunted Children in West Java, Indonesia: A Randomised Controlled Study Ummi Isti Izzati, Fetriyuna Fetriyuna, Siti Nur Fatimah, Adi Md Sikin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7998940/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A minute reduction in stunting rates from 21.6% in 2022 to 21.5% in 2023 called for more innovative strategies to address stunting in Indonesia. One such approach involves dietary supplementation with high-quality protein, which is essential for catch-up growth in stunted children. This study evaluated a 3-months intervention using protein-rich biscuits on the growth and nutritional status of stunted children aged 24–59 months in Garut Regency, West Java. The intervention group (30 children) consumed 10 pieces of high-protein biscuits (100 g/day, 16% protein), while the control group (25 children) received equivalent protein from eggs, tofu, and tempeh. The primary objective was to assess changes in height-for-age z-scores (HAZ), along with secondary outcomes like mid-upper arm circumference (MUAC), weight, height, weight-for-age (WAZ), and weight-for-height (WHZ). Results showed a significant improvement in HAZ for the intervention group (from − 2.43 to -2.30; Cohen's d = 0.69), while the control group saw no significant change (HAZ remained at -2.45; Cohen's d = 0.02). Additionally, the intervention group had greater gains in weight, height, and MUAC per gram of protein consumed, suggesting more efficient protein utilization. The results suggest that protein-rich biscuits using heat-treated soy protein concentrate could enhance protein bioavailability and digestibility. Biological sciences/Biochemistry Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Child growth dietary protein food nutritional status randomised controlled trial soy protein stunting Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Even after the initial 1000 days, its crucial for children to continue optimizing their growth as it significantly affects their health during their adolescence and adulthood (Martorell, 2017 ). Unfortunately inadequate nutrition can still lead to stunted growth. According to the World Health Organization (WHO), 2017 , stunting is defined as an issue related to growth and development marked by a height for age that falls more than two standard deviations below the median set by the WHO Child Growth Standards. Children who are stunted often face the risk of experiencing difficulties as adults, including decreased economic production and cognitive function impairments (Sudfeld et al., 2015 ; World Health organization (WHO), 2014 ). High-protein food interventions have emerged as a promising strategy to combat nutritional deficiencies by weight for age, height for age, and weight for height and other growth parameters (Andoyo et al., 2021 ). Although animal proteins have historically been the main source of high-quality protein, there is a growing trend toward plant-based proteins, such as soy due to public awareness on health and environment (Nishinari et al., 2014 ). This is particularly relevant given the global push towards more sustainable food systems and locally available resources, as highlighted in recent studies (Fetriyuna et al., 2021 ; Fetriyuna, Purwestri, et al., 2023; Komarulzaman et al., 2023 ). Soy protein, with a Protein Digestibility-Corrected Amino Acid Score (PDCAAS) of 1, is comparable in quality to animal proteins like meat and milk (Qin et al., 2022 ). With protein contents ranging from 40% to over 90%, a variety of soy-based products, such as soy flour, soy protein isolate (SPI), and soy protein concentrate (SPC), have been used as functional and nutritive dietary ingredients (Chhavi KM & VK, 2017). The significance of protein quality and bioavailability in the growth and development of children with stunting has been highlighted by recent research (Endrinikapoulos et al., 2023 ). The bioavailability and digestibility of protein, especially from plant-based sources like soy, are critical for optimizing development outcomes even while total protein consumption may satisfy general dietary requirements (Millward, 2017 ). The processing method employed during food preparation is one important component that improves the bioavailability and digestibility of soy protein (Sá et al., 2020 ). For example, the soy's proteins become denatured during the preheating process, disrupting hydrophobic interactions and hydrogen bonds (Damodaran & Paraf, 2017 ). This procedure enhances the protein's digestion in addition to producing a more accessible and open protein structure (Kelleher et al., 2020 ). Furthermore, the nutritional ecology of stunting implies that interventions need to take a more comprehensive approach, taking into consideration variables including food security, maternal health, and environmental conditions (Raiten & Bremer, 2020 ). Even though soy protein is known to have health benefits, there is limited study about how high-protein plant-based diets can help prevent childhood stunting. The majority of other research has concentrated on animal-based protein sources; however, little is known about the successful integration of plant-based substitutes, such as soy protein, into additional dietary treatments for stunted children (Mukhlis & Huriah, 2022 ). Additionally, much of the current research has focused on general nutritional outcomes for preventing stunting, with less attention given to the specific effects on growth parameters in children who are already experiencing stunting. Our study is particularly interested in preventing further decline in the growth of stunted children, recognizing that stunting is a complex and chronic condition which may require ongoing nutritional support rather than immediate improvement. In order to fill these gaps, this study examined the possible advantages of protein-rich soy biscuits prepared from modified soy protein concentrate on the growth characteristics of stunted children in West Java, Indonesia. This research aimed to examine the effect of soy-based interventions on height-for-age as a primary growth indicator of stunted children through a randomised controlled trial (RCT). 2. Key Messages • Persistent stunting in Indonesia necessitates innovative nutritional interventions, particularly for children who are already stunted. • High-quality plant-based proteins, such as soy, offer a sustainable and locally available alternative to animal proteins for addressing stunting. • Protein bioavailability and digestibility, enhanced through food processing techniques, play crucial roles in improving growth outcomes in stunted children. • This randomised controlled trial evaluated the impact of protein-rich soy biscuits on growth parameters of stunted children aged 24–59 months in West Java, Indonesia. • The study suggests potential benefits of supplementary foods using modified soy protein concentrate on height-for-age z-scores and other growth indicators in stunted children 3. Methods Study Design In this study, growth indicators of stunted children in West Java, Indonesia, are examined by a randomised controlled trial (RCT) to determine the effectiveness of protein-rich biscuits. The growth indicators included body weight, height, mid-upper arm circumference (MUAC), weight-for-age z-scores (WAZ), height-for-age z-scores (HAZ), and weight-for-height z-scores (WHZ). The intervention group received protein-rich biscuits containing 16% protein per 100 gram (each pouch containing 10 biscuits), and the control group received typical protein sources in the local diet such as egg, tofu, and tempeh with a protein level comparable to that of the biscuit. The growth of stunted children from both group was observed every four week for a period of three months. Trained enumerators conducted weekly home visits to monitor compliance, record consumption, and provide reinforcement. To ensure that the daily recommended supplements were consumed, caregivers were intructed not to change the children's typical meal intake during the trial. It was also emphasized that the biscuits must be consumed as snacks between main meals, not shared with other family members, and not be eaten as meal substitutes. All mothers and other caregivers in all groups were provided with nutrition information related to appropriate feeding, meal frequency, and hygienic practices. Caregivers in the intervention group were first counselled on how to store opened biscuits packs, daily quantity consumption and incorporation of the soy biscuits into child feeding. The control group continued with their usual diet following the nutritional education provided. The full trial protocol and statistical analysis plan can be accessed at Indonesia Clinical Research Registry of Health Ministry ( https://ina-crr.kemkes.go.id/id/studi/1095 ) with Registration No. INA-1909202525BA66D; First posted on 19/9/2025. Study Population The study population consisted of 55 children aged 24–59 months who are identified as stunted, with a height-for-age more than 2 standard deviations below the median of the WHO Child Growth Standards and Ministry of Health Indonesia. All study participants were under 59 months of age at the end of the 3-month intervention period. The stunted status of these children was confirmed by the local health centre as part of routine health assessments. Participants were recruited from four villages in Garut District, West Java, Indonesia: Salamnunggal, Margaluyu, Cangkuang, and Neglasari. The participants were divided into two groups: 30 children in the treatment group and 25 children in the control group. Inclusion criteria included children aged 24–59 months diagnosed as stunted (height-for-age z-score < -2 SD), with informed consent provided by parents or guardians. Exclusion criteria included children with severe stunting (HAZ < -3 SD), those with chronic diseases or congenital abnormalities affecting growth, and children participating in other nutritional intervention programs. The de-identified participant data, statistical code, and supporting materials are available from the corresponding author upon reasonable request. Data are not publicly available due to participant confidentiality and ethical restrictions. Randomization and Blinding Participants were randomly assigned to either the intervention group, who received protein-rich soy biscuits, or the control group, who received local protein sources with equivalent protein content. The random allocation sequence was generated using a lottery method to ensure random and unbiased group assignment. Each participant’s name was written on identical folded papers and drawn one by one until both groups were equally filled. Given the nature of the intervention, this was an open-label trial in which both participants and caregivers were aware of their group assignments. However, outcome assessors were blinded to group allocation to minimize measurement bias. Developing Protein-rich Soy Biscuits A 60:40 ratio of soy protein concentrate to corn starch was used to prepare the protein-rich soy biscuits following (Huda et al., 2023 ; Sutrisno et al., 2024 ), with a modification in flavour. Eggs, butter, cocoa powder, powdered sugar, baking powder, water, and a mineral premix (calcium, zinc, and iron) were added as complementary ingredients. According to (Huda et al., 2023 ; Khairina et al., 2025 ), unmodified high protein levels tend to increase hardness due to their structure-forming properties during baking. Corn starch was therefore included to enhance texture acceptability, especially for young children. Studies also show that corn starch has similar starch digestibility to wheat flour when baked at optimal temperatures (Conforti et al., 2012 ). Contextually, corn starch is locally available and provides a gluten-reduced alternative. To increase the digestibility of protein in the biscuits, the soy concentrate's protein was pasteurized at 90 \(\:℃\) for 30 min, which potentially denatured the protein and thus making it easier for digestive enzymes to break down (Fetriyuna, Lutfiah, et al., 2023 ). Furthermore, the biscuits were confirmed as protein-rich through laboratory analysis of macronutrient content, showing protein levels 3–4 times higher than typical commercial biscuits. Each serving is intended to contribute significantly to the daily protein nutritional adequacy rate (AKG) for children aged 3–5 years, which is 20–25 grams per child per day, as stipulated in Regulation of the Minister of Health of the Republic of Indonesia Number 28 of 2019. Outcome Measures The primary outcome was the change in height-for-age z-score (HAZ) from baseline to 3 months. Secondary outcomes included changes in weight, height, mid-upper arm circumference (MUAC), weight-for-age z-score (WAZ), and weight-for-height z-score (WHZ), as well as the incidence of adverse effects or infections during the study period. Anthropometric measurement data were gathered by qualified healthcare professionals following established protocols. Children were measured without shoes and with their feet together in height to the nearest 0.1 cm using a telescopic height rod (Seca 220, Hamburg, Germany). Weight was measured wearing the minimum necessary cloth with a medical scale (Seca 755, Hamburg, Germany) to nearest of grams at each time. Any adverse effect or health problems are documented during the protocol. No interim analyses or stopping guidelines were planned or conducted for this trial, as the intervention was of short duration and considered low risk. Statistical Analysis Data were analysed using intention-to-treat principles. Continuous variables (e.g., changes in z-scores) will be compared between groups using independent t-tests or Mann-Whitney U tests, depending on data distribution. Categorical variables will be compared using chi-square tests, with Cohen's d test employed to measure effect size. All analyses will be conducted using SPSS Software version 29 (IBM Corp), with a significance level set at 0.05. Ethical Considerations The study protocol has been reviewed and approved by the Ethics Committee of Universitas Padjadjaran, Indonesia. Informed consent is obtained from the parents or guardians of all participants before enrolment. Participants are free to withdraw from the study at any time without consequence. This trial was registered at Indonesia Clinical Research Registry of Health Ministry ( https://ina-crr.kemkes.go.id/id/studi/1095 ) with Registration No. INA-1909202525BA66D; First posted on 19/9/2025. 4. Results General Characteristics Out of 55 children enrolled in the study, 50 completed the trial, with 25 children each in the intervention and control groups. Five children assigned to receive the intervention decided not to continue in the research (Fig. 1 ). All randomized participants who completed the 12-week intervention were included in the final analysis according to their original group assignment (treatment or control group). Participants with incomplete data were excluded from the specific analysis, and the number of missing cases was reported for transparency. No subgroup or sensitivity analyses were prespecified or performed in this study. Harms were assessed systematically throughout the 12-week intervention period. Harms were defined as any adverse effects related to the intervention, such as allergic reactions, gastrointestinal symptoms, or other health complaints. These were assessed systematically at each weekly monitoring visit using a structured questionnaire administered to caregivers. Throughout the study, no side effects were reported, and no child missed more than two follow-up sessions. As shown in Table 1 , there was no significant (p > 0.05) difference between the intervention and control groups in terms of gender, age, duration of breastfeeding, initiation of complementary feeding, and parental education and occupation for the baseline characteristics. Additionally, household conditions were similar between the two groups, with comparable caregiver roles, the presence of siblings, and household facilities. The availability of in-house bathrooms and the frequency limiof meals and snacks were also not significantly (p > 0.05) different between the groups. Data on early childhood education attendance, caregiver characteristics (such as age, education level, and employment status), and household conditions were collected through structured questionnaires administered to caregivers at baseline. These data were analyzed using SPSS version 29 to apply descriptive statistics (means, frequencies, percentages) and chi-square . To address the potential for household clustering, it was noted that only two participants came from the same household, thus minimizing bias due to intra-household similarities. Compliance Rates of Consumption In this study, the rate of consumption compliance was monitored by recording daily intake on forms that were provided by researchers. A weekly checks was carried out by enumerators and researchers to make sure all documentation was accurate. As shown in Fig. 2 , the compliance rates over a three-month period varied dramatically across the intervention and control groups. The compliance from the intervention group decreased from 73% in the first month to 55% in the third. This decrease was attributed to potential boredom and satiety effects from the consistent consumption of biscuits. In contrast, the control group continued to exhibit great compliance ranging from 97% to 99%, possibly due to variety to a typical protrein sources. Statistical analysis using the Shapiro-Wilk test showed a normal distribution for the intervention group (p > 0.005) but a skewed distribution for the control group (p < 0.005). Mann-Whitney testing confirmed a significant difference in compliance between the two groups (Asymp. Sig. (2 tailed) < 0.005). These findings highlighted the challenges of maintaining long term dietary interventions and emphasized the importance of variety in programs to ensure continued compliance. Table 1 Baseline Characteristics of the Two Intervention Groups Parameters Total (n[%)]) Treatment (n[%]) Control (n[%]) p -value* Gender Male 27[54] 15[60] 12[48] 0.395 Female 23[46] 10[40] 13[52] Age (month) 24–35 14[28] 6[24] 8[32] 0.106 36–47 17[34] 12[48] 5[20] 48–59 19[38] 7[28] 12[48] Breastfeeding duration (month) ≤ 12 5[10] 3[12] 2[8] 0.894 13–24 43[86] 21[84] 22[88] ≥ 25 2[4] 1[4] 1[4] First complementary feeding (month) ≤ 5 1[2] 0[0] 1[4] 0.312 ≥ 6 49[98] 25[100] 24[96] Education of mother ES 8[16] 3[12] 5[20] 0.632 JHS 15[30] 8[32] 7[28] SHS 26[52] 14[56] 12[48] Diploma/Bachelor 1[2] 0[0] 1[4] Dead 0[0] 0[0] 0[0] Education of father ES 10[20] 6[24] 4[16] 0.775 JHS 12[24] 5[20] 7[14] SHS 25[50] 13[52] 12[48] Diploma/Bachelor 0[0] 0[0] 0[0] Dead 3[6] 1[2] 2[8] Occupation of mother Housewife 45[90] 23[92] 22[88] 0.600 Private Employee 4[8] 2[8] 2[8] Teacher/Lecturer 1[2] 0[0] 1[4] Occupation of father Dead/Unemployed 3[6] 1[4] 2[8] 0.940 Farmer 5[10] 3[12] 2[8] Laborer 27[54] 14[56] 13[52] Driver 3[6] 1[4] 2[8] Private Employee 7[14] 4[16] 3[12] Entrepreneur 5[10] 2[8] 3[12] Age of mother (year) 21–40 47[94] 24[96] 23[92] 0.552 > 41 3[6] 1[4] 2[8] Age of father (year) 21–40 35[70] 19[76] 16[64] 0.630 > 41 12[24] 5[20] 7[28] Dead 3[6] 1[4] 2[8] Mother was the caregiver Yes 47[94] 24[96] 23[92] 0.552 No 3[6] 1[4] 2[8] Father lives with the family Yes 45[90] 24[96] 21[84] 0.157 No 5[10] 1[4] 4[16] Number of 6- to 59-month-old siblings -excluding he/she- (child) 0 45[90] 23[92] 22[88] 0.637 1–2 5[10] 2[8] 3[12] > 3 0[0] 0[0] 0[0] Frequency of main meals per day (times) 1–2 14[28] 6[24] 8[32] 0.529 3–4 36[72] 19[76] 17[68] Frequency of snack per day (times) 1–2 26[52] 14[56] 12[48] 0.571 3–4 24[48] 11[44] 13[52] Availability of bathroom in the house Available 48[96] 24[96] 24[96] 1.000 Not Available 2[4] 1[4] 1[4] ES = Elementary School, JHS = Junior High School, SHS = Senior High School *Chi-Square Test Growth Indicators A statistical analysis for each growth indicator was conducted to determine if the intervention caused a significant change between intervention and control group. Prior to this, a normality test was performed using SPSS v.29 software to confirm that the data was adhered to a distribution. Subsequently, a paired sample T-test was carried out also using SPSS v.29 software with the findings presented in Table 2 . Moreover, Cohen's d was computed to quantify the effect size, indicating the magnitude of the difference between the two groups. Table 2 Changes in growth indicators after 12-weeks intervention Indicators Group Before After Mean Difference 95% CI p- value * Cohen’s d Average SD Average SD Lower Upper Weight (kg) Treatment 11.98 1.84 12.74 1.90 0.764 -0.931 -0.597 0.000 1.87 Control 11.64 1.83 12.46 1.82 0.820 -0.961 -0.679 0.000 2.40 Height (cm) Treatment 88.55 6.01 90.4 5.97 2.020 -2.310 -1.730 0.000 2.88 Control 88.82 6.75 90.43 6.71 1.612 -1.833 -1.392 0.000 3.02 MUAC (cm) Treatment 15.45 1.10 15.92 1.14 0.467 -0.547 -0.398 0.000 2.42 Control 14.73 1.06 15.10 1.04 0.364 -0.417 -0.311 0.000 2.83 WAZ Treatment -1.56 0.67 -1.41 0.57 0.146 -0.289 0.002 0.047 0.42 Control -1.84 0.57 -1.63 0.49 0.212 -0.394 0.031 0.024 0.28 HAZ Treatment -2.43 0.31 -2.30 0.36 0.121 -0.194 -0.048 0.004 0.69 Control -2.45 0.30 -2.45 0.33 0.003 -0.060 -0.066 0.000 0.02 WHZ Treatment -0.49 0.95 -0.21 0.89 0.278 -0.511 0.044 0.022 0.49 Control -0.86 0.69 -0.42 0.72 0.440 -0.607 0.273 0.000 1.09 CI: Confidence Interval, MUAC = mid-upper arm circumference, WAZ = weight-for-age z-scores, HAZ = height-for-age z-scores, WHZ = weight-for-height z-scores. *Paired Sample T-Test As shown in Table 2 , there was a positive change (p < 0.05) in various growth indicators for the both groups after a period of twelve weeks. Based on Cohen's d value, the effect size indicated a moderate to large difference between the two groups, indicating the substantial impact on growth outcomes. Both groups experienced substantial weight gain, with the intervention group showing an average increase of 0.764 kg (95% CI: -0.931 to -0.597, p < 0.05) and the control group a slightly higher increase of 0.82 kg (95% CI: -0.961 to -0.679, p < 0.05). These changes were statistically significant (p < 0.05) with large effect sizes according to Cohen's d, though the control group had a slightly higher effect (2.4 vs 1.87). Linear growth also showed positive trends, with the intervention group increasing by an average of 2.02 cm (95% CI: -2.31 to -1.73, p < 0.05) and the control group by 1.61 cm (95% CI: -1.833 to -1.392, p < 0.05). The effect on height was substantial in both groups, with Cohen's d exceeding 2.8. MUAC indicator also improved with the intervention group increasing by 0.467 cm (95% CI: -0.547 to -0.398, p < 0.05) and the control group by 0.364 cm (95% CI: -0.417 to -0.311, p < 0.05), both with large effect sizes (2.42 vs 2.88). A moderate effect of WAZ was noted from intervention group with a Cohens’ d value of 0.42. However, only a small effect of WAZ was observed from the control group with a Cohen’s d value of 0.28. Interestingly, a large effect of HAZ was recorded from the intervention group with a Cohens’ d value of 0.69, but the control group showed no significant change. WHZ in the control group exhibited a greater increase and a large effect (Cohen’s d 1.09) compared to a moderate effect in the intervention group (Cohen’s d 0.49). This may indicate that children in the control group experienced a rapid weight gain without corresponding height growth, which resulted higher WHZ scores. Impact of Compliance Rates on Nutritional Status Changes To gain more insight into the relationship between intervention compliance and nutritional status, the changes in growth indicators in the two groups during the course of the trial were analysed. Figures 3 and 4 illustrated the relationship between compliance rates (%) and changes in nutritional status for the intervention and control groups, respectively. As shown in Fig. 3, the compliance rate of the intervention group was 73% in the first month, with a negative relationship with WAZ (-0.06), but a positive relationship with HAZ (0.04) and WHZ (0.01). This means that while compliance to the protein-rich biscuit intake was relatively high, improvements in nutritional status, particularly in WAZ and WHZ, were not yet significant, possibly due to an initial adaptation period. In the second month, the compliance rate dropped to 63% but showed a positive relationship with all z-score indicators: WAZ (0.10), HAZ (0.04), and WHZ (0.13). This indicated better improvements in nutritional status as children's bodies began to adjust to the intervention. By the third month, compliance rate further declined to 55%, yet the positive relationship with WAZ (0.12), HAZ (0.05), and WHZ (0.10) persisted, suggesting that nutritional status continued to improve despite lower compliance. Figure 3. Compliance Rates vs Nutritional Status Changes in the Treatment Group (WAZ = Weight-for-age z-score, HAZ = Height-for-age z-score, WHZ = Weight-for-height z-score) As shown in Fig. 4 , there were positive changes in nutritional indicators over 3 months along with consistently high rates of compliance exhibited by the control group. In the first month, the compliance rate stood at 99% with improvements noted in WAZ, WHZ and HAZ. In the second month, the compliance rate was slightly decreased to 94%, but WAZ increased (0.06) and WHZ decreased to 0.08 while HAZ persisted. The third month showed a major improvement in WHZ by 0.196, a minor fall in HAZ (-0.03), a slight increase in WAZ (0.10), with compliance rate of 97%. These differences in growth measures despite of compliance rate fluctuations suggest complex linkages between food intake and growth trends in the control group during the study. Additional Protein Intake Contribution to Anthropometric and Nutritional Changes The effects of protein consumption on anthropometry and nutritional status of stunted children were shown in Table 3 . This analysis of anthropometry and nutritional status aimed to evaluate how efficiently protein from both sources was utilized by the body for growth in both groups. The treatment group had an average compliance rate of 64% (SD = 7%), resulting in an average additional daily protein intake of 10.24 grams (SD = 1.18). Over 30 days, this group consumed a total of 307.2 grams of additional protein (SD = 35.3). In contrast, the control group exhibited a higher compliance rate of 97% (SD = 2%), with an average daily protein intake of 15.47 grams (SD = 0.33), accumulating to 464.0 grams of additional protein over 30 days (SD = 9.86). The significance of the groups differences was assessed using the independent sample t-test, and for these indicators showed statistically significant differences between the treatment and control groups with the same values (p < 0.05). The analyses of weight gain per gram of protein consumed in the treatment group discovered that the treatment group achieved a higher efficiency, with a weight gain of 0.9 grams per gram of protein consumed (SD = 0.3). Conversely, the control group showed a lower weight gain of 0.6 grams per gram of protein (SD = 0.1). The siginificant test indicated that this difference was statistically significant (p < 0.05). For height improvement, the treatment group exhibited an increase of 0.0022 cm per gram of protein (SD = 0.0004), while the control group had a smaller height gain of 0.0012 cm per gram of protein (SD = 0.0002). A significant difference also found between the groups for this indicators (p < 0.05). Table 3 Protein Intake Contribution to Anthropometric and Nutritional Changes Indicators Group Score SD p-value * Average of compliance rates (%) Treatment 64 7 0.004 Control 97 2 Average of additional protein intake per day (g) Treatment 10.24 1.18 0.004 Control 15.47 0.33 Average of additional protein intake after 3 months (g) Treatment 307.2 35.3 0.004 Control 464.0 9.86 Weight gain per gram protein (g) Treatment 0.9 0.3 0.028 Control 0.6 0.1 Height gain per gram protein (cm) Treatment 0.0022 0.0004 0.027 Control 0.0012 0.0002 MUAC gain per gram protein (cm) Treatment 0.0005 0.0002 0.178 Control 0.0003 0.0000 WAZ gain per gram protein Treatment 0.0003 0.0001 0.033 Control 0.0002 0.0000 HAZ gain per gram protein Treatment 0.0001 0.0000 0.020 Control 0.0000 0.0000 WHZ gain per gram protein Treatment 0.0003 0.0002 0.015 Control 0.0003 0.0001 SD = standard deviation, MUAC = mid-upper arm circumference, WAZ = weight-for-age z-scores, HAZ = height-for-age z-scores, WHZ = weight-for-height z-scores. *Independent Sample T-Test The treatment group had higher MUAC gain per gram of protein showing an increase of 0.0005 cm (SD = 0.0002) as compared to 0.0003 cm (SD = 0.0000) in the control group, but this slight difference was not statistically significant (p > 0.05). For WAZ gain per gram of protein the treatment group showed 0.0003 (SD = 0.0001) while the control group had 0.0002 (SD = 0.0000), which was statistically significant (p < 0.05). The HAZ of the treatment group was 0.0001 (SD = 0.0000), and no improvement was observed in the control group (0.0000, SD = 0.0000), with the difference was found statistically significant (p = 0.020). Nevertheless, both groups showed equal improvements in WHZ per gram of protein, with a gain of 0.0003 in the treatment group (SD = 0.0002) and 0.0003 in the control group (SD = 0.0001), also this change was statistically significant (p < 0.05). 5. Discussion Our study in Garut Regency, West Java, shows some promising results for using protein-rich biscuits to promote the growth of stunted children aged 24–59 months. Over 3 months, some improvements in growth indicators for both groups were noted, but there were some interesting differences worth discussing. Interestingly, despite lower compliance (64% vs. 97%) and consequently lower overall protein intake in the treatment group, the children demonstrated more efficient protein utilization. For example, the HAZ of treatment group was improved from − 2.43 to -2.30, with a substantial effect size (Cohen's d = 0.69), indicating progress in addressing stunting. However, it is important to address that these children remained clinically stunted (z-score < -2 SD), underscoring the persistent nature of this condition. In contrast, the HAZ of control group remained unchanged at -2.45 (Cohen's d = 0.02). The protein from the biscuits appeared to contribute more effectively to growth parameters. For example, the treatment group showed greater increases in body weight (0.9 g vs. 0.6 g) and height (0.0022 cm vs. 0.0012 cm) for each gram of protein consumed as compared to the control group. This suggests that the protein-rich biscuits may have enhanced bioavailability or have been better suited for supporting growth in stunted children than other protein from local sources. Moreover, protein quality can also be improved by performing thermal heating in the process of biscuits production which leads to the aggregation of protein, resulting in decreased protein solubility. The sensitivity of protein to the heating process can be harnessed to modify its properties (Andoyo et al., 2015 ). In this case, specifically denaturing the protein can enhance the digestibility of protein. The digestibility of protein in the body provides an indication of the quality of the protein consumed. The easier a protein to digest in the body, the higher the quality of the protein (Adhikari et al., 2022 ; Ketnawa & Ogawa, 2021 ) . The treatment group exhibited superior improvements in MUAC per gram of protein (0.0005 cm vs. 0.0003 cm), indicating more effective enhancement of muscle mass and overall nutritional status. The more pronounced gains in WAZ and HAZ per gram of protein in the treatment group further emphasized the enhanced growth outcomes associated with the feeding of protein-rich biscuits. These findings are consistent with previous research highlighing the effectiveness of soy-based nutritional interventions in improving the growth and nutritional status of malnourished children. For example, the children in Hanoi, Vietnam with severe acute malnutrition who consumed soy and mung bean-based ready-to-use therapeutic food (RUTF) (15% protein per 100 grams) showed significant improvements in nutritional status after four weeks. The children were reported to show an average weight gain of 0.64 kg, height increases of 0.7 cm, and improvements in WAZ, HAZ, and WHZ scores (Nga et al., 2013 ). Furthermore, soy-based lipid nutrient supplements (LNS) were provided to infants in rural Malawi and the results showed that infants who received soy-LNS had a slight decrease in the incidence of severe stunting (9.1%) (Mangani et al., 2015 ). Similarly, research conducted in Tehran, Iran, demonstrated that children with mild to moderate malnutrition who received a local ready-to-use supplementary food (RUSF) containing soy protein isolate for eight weeks experienced significant increases in body weight and body mass index as compared to a control group on a normal diet (Azimi et al., 2020 ). An intervention in Luapala, Zambia, where stunted and underweight children were fed soy-corn porridge (13.5% protein per 100 grams) over a 12-month period, produced notable increases in height and weight, adding more evidence to this picture (Masuda & Chitundu, 2019 ). Furthermore, a study reported that malnourished children in Dhaka, Bangladesh, gained an average of 3.9 (± 3.2) kg over the course of four months when they were fed soy-based RUTF and containing 14.5% protein (Hossain et al., 2020 ). Similarly, a study found that children who were given soy-corn porridge containing 15% protein for 12 days and were classified as moderately or severely malnourished gained an average body weight of 35.45 g per day (Lalèyè et al., 2023 ). It was also shown that children with acute malnutrition in Bogor, Indonesia, who received soy-based RUTF for eight weeks gained more than 2 g/kg/day of body weight in comparison with other RUTF (Rachmadewi et al., 2023 ). These consistencies across studies strengthen the evidence for protein-rich interventions in addressing child malnutrition. The beneficial effects of the protein-rich biscuit intervention on the nutritional status and growth of stunted children emphasize the need for not only consuming adequate protein, but also the quality and bioavailability of that protein. The treatment group exhibited better growth outcomes than the control group, with notable improvements in HAZ and higher protein utilization efficiency. These findings raise the possibility that the children's bodies were able to absorb and utilize the modified protein in the biscuits more efficiently. This result was consistent with a recent study on cookies enriched with 20% soymeal flour, which also showed the best results in terms of antioxidant and nutritional qualities. These fortified cookies had higher calcium and iron content, enhanced organoleptic qualities, and increased total soluble phenolic contents, contributing to stronger antioxidant capacities and greater health benefits (Ghoshal & Kaushik, 2020 ). The effectiveness of the soy protein-based products emphasizes how crucial it is to include high-quality, bioavailable protein sources in nutritional treatments, especially for vulnerable groups like stunted children (Endrinikapoulos et al., 2023 ) This improved use of protein can be partially ascribed to the biscuit production process, specifically the pre-heating stage. During pre-heating, the proteins in the raw materials undergo denaturation, a process that disrupts hydrogen bonds and hydrophobic interactions, leading to changes in protein structure (Damodaran & Paraf, 2017 ; Kelleher et al., 2020 ). These changes, while initially causing protein aggregation, ultimately result in a more open and accessible structure that can improve the digestibility of the protein (Andoyo et al., 2023 ; Fetriyuna, Lutfiah, et al., 2023 ). A study dicovered that thermal processing greatly increase the digestibility of soy protein isolate (SPI) and increases the bioavailability of protein in diets based on soy (Pereira et al., 2019 ). For stunted children, who often face challenges in nutrient absorption, the denatured protein in the biscuits may be more easily broken down by digestive enzymes, increasing the bioavailability of essential amino acids crucial for growth. This improved digestibility is linked to a higher Protein Efficiency Ratio (PER), which measures the protein's ability to support growth (Huangfu et al., 2024 ; Smolin et al., 2020 ). A study showed that the digestibility of amino acids in stunted children improves significantly after the heat and pressure processing of plant proteins, which inactivates trypsin inhibitors while retaining essential amino acids like lysine and proline (Devi et al., 2020 ; Sá et al., 2020 ). The fact that each gram of protein in the treatment group contributed more to weight gain and height increase compared to the control group underscores the effectiveness of the modified soy protein in the biscuits. Furthermore, the process of denaturation and subsequent protein modification not only improved digestibility but also likely inactivated anti-nutritional factors such as trypsin inhibitors, which are known to interfere with protein digestion. The retention of essential amino acids, such as lysine and proline, during the biscuit-making process would have further contributed to the improved growth parameters observed in the treatment group (Amigo & Hernández-Ledesma, 2020 ; Devi et al., 2020 ; Fetriyuna, Lutfiah, et al., 2023 ). Fortified soy-based foods also can further enhance these nutritional benefits by adding additional vitamins and minerals as a potential growth booster in stunted children (Endrinikapoulos et al., 2023 ). Limitations of the Study It is imperative to acknowledge the importance of a varied diet and micronutrient intake although the current study mainly focused on the effect of protein-rich biscuits to the stunted children. This is because meals rich in many vitamins and minerals are also key to physiological growth and development. For instance, micronutrients like zinc, iron and vitamin A are known to be growth promoters. Future studies could look into the interaction between protein and micronutrient sufficiency to get a better understanding of dietary strategies for stunting. Moreover, the present study did not exclude children with mild or acute illnesses, and it did not incorporate a 24-hour dietary recall to capture the overall dietary intake, as the primary objective was to assess the effect of protein-rich biscuits as a supplementary intervention. These unmeasured variables may have influenced the findings. Therefore, future studies should take these variables into considerations to provide a more complete picture of protein rich interventions and stunting. 6. Conclusion The protein-rich biscuit intervention had a potential and positive impact of controlling nutritional status of stunted children, particularly in HAZ. Significant anthropometric improvements and improved protein utilization were noted in the therapy group despite decreased compliance. It is important to highlight that both quantity and quality of protein are considered in addressing stunting. In this regard, the pre-heating process in the production of protein-rich biscuits plays a crucial role in enhancing the bioavailability of protein, thereby making it more effective in supporting the growth and nutritional mitigation of stunted children. However, limitations such as exclusion of children with mild and acute illness and 24-h food recall method could have impacted the outcomes. Future research should look into long term effect and scalability of the intervention, protein-micronutrient interaction and non-nutritional factors to better understand and address stunting. Declarations Ethical Statement This study received ethical approval from the Research Ethics Committee of Universitas Padjadjaran, Bandung. The approval was granted under the reference number 280/UN6.KEP/EC/2024. All research procedures were conducted in accordance with the ethical standards set forth by this committee and adhered to the principles of the Declaration of Helsinki. Clinical trial number: INA-1909202525BA66D. Human Ethics and Consent to Participate Written informed consent was obtained from the parents or legal guardians of all participating children prior to enrollment. Participants' confidentiality and anonymity were strictly maintained throughout the study. The study did not involve the collection or use of any personally identifiable data. Availability of Data and Materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Funding Information Program Riset Kolaborasi Indonesia (Indonesia Collaborative Research Program). AUTHOR CONTRIBUTION UII was responsible for field data collection related to the intervention, including coordinated the biscuit production process and ensured timely delivery of both the soy-based biscuits and standard protein foods to the study sites, also handled all necessary permit processes with local authorities. In addition, she contributed to the statistical analysis and was a major contributor in drafting the manuscript. FF supervised the field activities and conducted community coordination, including providing nutrition education to caregivers and engaging with local stakeholders such as health workers and health centre staff. She also contributed to validation and provided material, literature and technical support. SNF, a medical doctor specializing in clinical nutrition, served as a consultant throughout the intervention phase, advising on study execution and troubleshooting field challenges. She also contributed to the ethical clearance process, revised the manuscript with a focus on interpreting intervention outcomes, and ensured coherence in evaluating the findings. AMS provided input and suggestions on the presentation of the results, including tables and figures. He also participated in technical writing, editing for language clarity, and enhancing the overall presentation of the study's findings. RA conceptualized and designed the study, including the laboratory trial and formulation of the soy-based biscuits, and supervised the industrial-scale production. He oversaw the implementation of the intervention in the study communities, critically revised the manuscript for important intellectual content, and secured funding for the study. All authors read and approved the final manuscript. 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09:22:42","extension":"png","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":11879,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinegroupimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/d99f753a916b64b51b195236.png"},{"id":97434723,"identity":"1c962ec4-0365-4f5c-8b9f-f8043c55cb3c","added_by":"auto","created_at":"2025-12-04 10:54:31","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":149140,"visible":true,"origin":"","legend":"","description":"","filename":"fdd0d9c9222749e5b87bcb3bf034a61a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/0cc03b9fc3890dc17707a324.xml"},{"id":97666946,"identity":"05fea535-8fdb-407e-b15a-dd177ae699c5","added_by":"auto","created_at":"2025-12-08 09:22:31","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":163894,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/7cc6ac6d8faad3228ebfb5d5.html"},{"id":97434706,"identity":"f00fceca-4706-4c1d-a761-5ff8a4bc6b43","added_by":"auto","created_at":"2025-12-04 10:54:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62648,"visible":true,"origin":"","legend":"\u003cp\u003eStudy protocol flowchart adhering to the Consolidated Standards of Reporting Trials (CONSORT) guidelines\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/89ed9c39de14257cfb636a28.png"},{"id":97667561,"identity":"8599f0b6-ef1a-42e5-b9fe-f983294b09ca","added_by":"auto","created_at":"2025-12-08 09:23:46","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":138856,"visible":true,"origin":"","legend":"\u003cp\u003eComparison for Compliance Rates of Consumption\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/e50487d1f14155ee97af52fb.jpeg"},{"id":97434707,"identity":"97c11e8f-32ab-495d-b5d5-9d262293260b","added_by":"auto","created_at":"2025-12-04 10:54:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":83791,"visible":true,"origin":"","legend":"\u003cp\u003eCompliance Rates vs Nutritional Status Changes in the Treatment Group (WAZ= Weight-for-age z-score, HAZ= Height-for-age z-score, WHZ= Weight-for-height z-score)\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/84155677bb8b195a43808f58.png"},{"id":97667755,"identity":"570ddd3f-050e-4415-b41e-00d4c206cd51","added_by":"auto","created_at":"2025-12-08 09:24:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":69801,"visible":true,"origin":"","legend":"\u003cp\u003eCompliance Rates vs Nutritional Status Changes in the Control Group (WAZ= Weight-for-age z-score, HAZ= Height-for-age z-score, WHZ= Weight-for-height z-score)\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/0874ece3b2233382513dedc8.png"},{"id":103913686,"identity":"1299e8ef-95c0-4b63-9c87-1d06b0be22cf","added_by":"auto","created_at":"2026-03-04 12:42:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1390392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7998940/v1/d84686a9-7d7b-4931-bedd-a13f2dbfaf28.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEfficacy of Protein-Rich Soy Biscuits on Growth Parameters of Stunted Children in West Java, Indonesia: A Randomised Controlled Study\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003e\u003c/p\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEven after the initial 1000 days, its crucial for children to continue optimizing their growth as it significantly affects their health during their adolescence and adulthood (Martorell, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Unfortunately inadequate nutrition can still lead to stunted growth. According to the World Health Organization (WHO), \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2017\u003c/span\u003e, stunting is defined as an issue related to growth and development marked by a height for age that falls more than two standard deviations below the median set by the WHO Child Growth Standards. Children who are stunted often face the risk of experiencing difficulties as adults, including decreased economic production and cognitive function impairments (Sudfeld et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; World Health organization (WHO), \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHigh-protein food interventions have emerged as a promising strategy to combat nutritional deficiencies by weight for age, height for age, and weight for height and other growth parameters (Andoyo et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although animal proteins have historically been the main source of high-quality protein, there is a growing trend toward plant-based proteins, such as soy due to public awareness on health and environment (Nishinari et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). This is particularly relevant given the global push towards more sustainable food systems and locally available resources, as highlighted in recent studies (Fetriyuna et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Fetriyuna, Purwestri, et al., 2023; Komarulzaman et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Soy protein, with a Protein Digestibility-Corrected Amino Acid Score (PDCAAS) of 1, is comparable in quality to animal proteins like meat and milk (Qin et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). With protein contents ranging from 40% to over 90%, a variety of soy-based products, such as soy flour, soy protein isolate (SPI), and soy protein concentrate (SPC), have been used as functional and nutritive dietary ingredients (Chhavi KM \u0026amp; VK, 2017).\u003c/p\u003e\u003cp\u003eThe significance of protein quality and bioavailability in the growth and development of children with stunting has been highlighted by recent research (Endrinikapoulos et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The bioavailability and digestibility of protein, especially from plant-based sources like soy, are critical for optimizing development outcomes even while total protein consumption may satisfy general dietary requirements (Millward, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The processing method employed during food preparation is one important component that improves the bioavailability and digestibility of soy protein (Sá et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). For example, the soy's proteins become denatured during the preheating process, disrupting hydrophobic interactions and hydrogen bonds (Damodaran \u0026amp; Paraf, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). This procedure enhances the protein's digestion in addition to producing a more accessible and open protein structure (Kelleher et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Furthermore, the nutritional ecology of stunting implies that interventions need to take a more comprehensive approach, taking into consideration variables including food security, maternal health, and environmental conditions (Raiten \u0026amp; Bremer, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEven though soy protein is known to have health benefits, there is limited study about how high-protein plant-based diets can help prevent childhood stunting. The majority of other research has concentrated on animal-based protein sources; however, little is known about the successful integration of plant-based substitutes, such as soy protein, into additional dietary treatments for stunted children (Mukhlis \u0026amp; Huriah, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Additionally, much of the current research has focused on general nutritional outcomes for preventing stunting, with less attention given to the specific effects on growth parameters in children who are already experiencing stunting. Our study is particularly interested in preventing further decline in the growth of stunted children, recognizing that stunting is a complex and chronic condition which may require ongoing nutritional support rather than immediate improvement.\u003c/p\u003e\u003cp\u003eIn order to fill these gaps, this study examined the possible advantages of protein-rich soy biscuits prepared from modified soy protein concentrate on the growth characteristics of stunted children in West Java, Indonesia. This research aimed to examine the effect of soy-based interventions on height-for-age as a primary growth indicator of stunted children through a randomised controlled trial (RCT).\u003c/p\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"2. Key Messages","content":"\u003cp\u003e• Persistent stunting in Indonesia necessitates innovative nutritional interventions, particularly for children who are already stunted.\u003c/p\u003e\u003cp\u003e • High-quality plant-based proteins, such as soy, offer a sustainable and locally available alternative to animal proteins for addressing stunting.\u003c/p\u003e\u003cp\u003e• Protein bioavailability and digestibility, enhanced through food processing techniques, play crucial roles in improving growth outcomes in stunted children.\u003c/p\u003e\u003cp\u003e• This randomised controlled trial evaluated the impact of protein-rich soy biscuits on growth parameters of stunted children aged 24–59 months in West Java, Indonesia.\u003c/p\u003e\u003cp\u003e• The study suggests potential benefits of supplementary foods using modified soy protein concentrate on height-for-age z-scores and other growth indicators in stunted children\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn this study, growth indicators of stunted children in West Java, Indonesia, are examined by a randomised controlled trial (RCT) to determine the effectiveness of protein-rich biscuits. The growth indicators included body weight, height, mid-upper arm circumference (MUAC), weight-for-age z-scores (WAZ), height-for-age z-scores (HAZ), and weight-for-height z-scores (WHZ).\u003c/p\u003e\u003cp\u003eThe intervention group received protein-rich biscuits containing 16% protein per 100 gram (each pouch containing 10 biscuits), and the control group received typical protein sources in the local diet such as egg, tofu, and tempeh with a protein level comparable to that of the biscuit. The growth of stunted children from both group was observed every four week for a period of three months. Trained enumerators conducted weekly home visits to monitor compliance, record consumption, and provide reinforcement.\u003c/p\u003e\u003cp\u003eTo ensure that the daily recommended supplements were consumed, caregivers were intructed not to change the children's typical meal intake during the trial. It was also emphasized that the biscuits must be consumed as snacks between main meals, not shared with other family members, and not be eaten as meal substitutes. All mothers and other caregivers in all groups were provided with nutrition information related to appropriate feeding, meal frequency, and hygienic practices. Caregivers in the intervention group were first counselled on how to store opened biscuits packs, daily quantity consumption and incorporation of the soy biscuits into child feeding. The control group continued with their usual diet following the nutritional education provided.\u003c/p\u003e\u003cp\u003eThe full trial protocol and statistical analysis plan can be accessed at Indonesia Clinical Research Registry of Health Ministry (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ina-crr.kemkes.go.id/id/studi/1095\u003c/span\u003e\u003cspan address=\"https://ina-crr.kemkes.go.id/id/studi/1095\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) with Registration No. INA-1909202525BA66D; First posted on 19/9/2025.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy Population\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study population consisted of 55 children aged 24\u0026ndash;59 months who are identified as stunted, with a height-for-age more than 2 standard deviations below the median of the WHO Child Growth Standards and Ministry of Health Indonesia. All study participants were under 59 months of age at the end of the 3-month intervention period. The stunted status of these children was confirmed by the local health centre as part of routine health assessments. Participants were recruited from four villages in Garut District, West Java, Indonesia: Salamnunggal, Margaluyu, Cangkuang, and Neglasari. The participants were divided into two groups: 30 children in the treatment group and 25 children in the control group.\u003c/p\u003e\u003cp\u003eInclusion criteria included children aged 24\u0026ndash;59 months diagnosed as stunted (height-for-age z-score \u0026lt; -2 SD), with informed consent provided by parents or guardians. Exclusion criteria included children with severe stunting (HAZ \u0026lt; -3 SD), those with chronic diseases or congenital abnormalities affecting growth, and children participating in other nutritional intervention programs. The de-identified participant data, statistical code, and supporting materials are available from the corresponding author upon reasonable request. Data are not publicly available due to participant confidentiality and ethical restrictions.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRandomization and Blinding\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants were randomly assigned to either the intervention group, who received protein-rich soy biscuits, or the control group, who received local protein sources with equivalent protein content. The random allocation sequence was generated using a lottery method to ensure random and unbiased group assignment. Each participant\u0026rsquo;s name was written on identical folded papers and drawn one by one until both groups were equally filled. Given the nature of the intervention, this was an open-label trial in which both participants and caregivers were aware of their group assignments. However, outcome assessors were blinded to group allocation to minimize measurement bias.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDeveloping Protein-rich Soy Biscuits\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA 60:40 ratio of soy protein concentrate to corn starch was used to prepare the protein-rich soy biscuits following (Huda et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sutrisno et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), with a modification in flavour. Eggs, butter, cocoa powder, powdered sugar, baking powder, water, and a mineral premix (calcium, zinc, and iron) were added as complementary ingredients. According to (Huda et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Khairina et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), unmodified high protein levels tend to increase hardness due to their structure-forming properties during baking. Corn starch was therefore included to enhance texture acceptability, especially for young children. Studies also show that corn starch has similar starch digestibility to wheat flour when baked at optimal temperatures (Conforti et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Contextually, corn starch is locally available and provides a gluten-reduced alternative.\u003c/p\u003e\u003cp\u003eTo increase the digestibility of protein in the biscuits, the soy concentrate's protein was pasteurized at 90\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:℃\\)\u003c/span\u003e\u003c/span\u003e for 30 min, which potentially denatured the protein and thus making it easier for digestive enzymes to break down (Fetriyuna, Lutfiah, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Furthermore, the biscuits were confirmed as protein-rich through laboratory analysis of macronutrient content, showing protein levels 3\u0026ndash;4 times higher than typical commercial biscuits. Each serving is intended to contribute significantly to the daily protein nutritional adequacy rate (AKG) for children aged 3\u0026ndash;5 years, which is 20\u0026ndash;25 grams per child per day, as stipulated in Regulation of the Minister of Health of the Republic of Indonesia Number 28 of 2019.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome Measures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe primary outcome was the change in height-for-age z-score (HAZ) from baseline to 3 months. Secondary outcomes included changes in weight, height, mid-upper arm circumference (MUAC), weight-for-age z-score (WAZ), and weight-for-height z-score (WHZ), as well as the incidence of adverse effects or infections during the study period. Anthropometric measurement data were gathered by qualified healthcare professionals following established protocols. Children were measured without shoes and with their feet together in height to the nearest 0.1 cm using a telescopic height rod (Seca 220, Hamburg, Germany). Weight was measured wearing the minimum necessary cloth with a medical scale (Seca 755, Hamburg, Germany) to nearest of grams at each time. Any adverse effect or health problems are documented during the protocol. No interim analyses or stopping guidelines were planned or conducted for this trial, as the intervention was of short duration and considered low risk.\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistical Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData were analysed using intention-to-treat principles. Continuous variables (e.g., changes in z-scores) will be compared between groups using independent t-tests or Mann-Whitney U tests, depending on data distribution. Categorical variables will be compared using chi-square tests, with \u003cem\u003eCohen's d\u003c/em\u003e test employed to measure effect size. All analyses will be conducted using SPSS Software version 29 (IBM Corp), with a significance level set at 0.05.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEthical Considerations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe study protocol has been reviewed and approved by the Ethics Committee of Universitas Padjadjaran, Indonesia. Informed consent is obtained from the parents or guardians of all participants before enrolment. Participants are free to withdraw from the study at any time without consequence. This trial was registered at Indonesia Clinical Research Registry of Health Ministry (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ina-crr.kemkes.go.id/id/studi/1095\u003c/span\u003e\u003cspan address=\"https://ina-crr.kemkes.go.id/id/studi/1095\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ) with Registration No. INA-1909202525BA66D; First posted on 19/9/2025.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003e\u003cb\u003eGeneral Characteristics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOut of 55 children enrolled in the study, 50 completed the trial, with 25 children each in the intervention and control groups. Five children assigned to receive the intervention decided not to continue in the research (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). All randomized participants who completed the 12-week intervention were included in the final analysis according to their original group assignment (treatment or control group). Participants with incomplete data were excluded from the specific analysis, and the number of missing cases was reported for transparency. No subgroup or sensitivity analyses were prespecified or performed in this study.\u003c/p\u003e\u003cp\u003eHarms were assessed systematically throughout the 12-week intervention period. Harms were defined as any adverse effects related to the intervention, such as allergic reactions, gastrointestinal symptoms, or other health complaints. These were assessed systematically at each weekly monitoring visit using a structured questionnaire administered to caregivers. Throughout the study, no side effects were reported, and no child missed more than two follow-up sessions. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there was no significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) difference between the intervention and control groups in terms of gender, age, duration of breastfeeding, initiation of complementary feeding, and parental education and occupation for the baseline characteristics. Additionally, household conditions were similar between the two groups, with comparable caregiver roles, the presence of siblings, and household facilities. The availability of in-house bathrooms and the frequency limiof meals and snacks were also not significantly (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) different between the groups.\u003c/p\u003e\u003cp\u003eData on early childhood education attendance, caregiver characteristics (such as age, education level, and employment status), and household conditions were collected through structured questionnaires administered to caregivers at baseline. These data were analyzed using SPSS version 29 to apply descriptive statistics (means, frequencies, percentages) and \u003cem\u003echi-square\u003c/em\u003e. To address the potential for household clustering, it was noted that only two participants came from the same household, thus minimizing bias due to intra-household similarities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCompliance Rates of Consumption\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn this study, the rate of consumption compliance was monitored by recording daily intake on forms that were provided by researchers. A weekly checks was carried out by enumerators and researchers to make sure all documentation was accurate. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the compliance rates over a three-month period varied dramatically across the intervention and control groups. The compliance from the intervention group decreased from 73% in the first month to 55% in the third. This decrease was attributed to potential boredom and satiety effects from the consistent consumption of biscuits. In contrast, the control group continued to exhibit great compliance ranging from 97% to 99%, possibly due to variety to a typical protrein sources. Statistical analysis using the Shapiro-Wilk test showed a normal distribution for the intervention group (p\u0026thinsp;\u0026gt;\u0026thinsp;0.005) but a skewed distribution for the control group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005). Mann-Whitney testing confirmed a significant difference in compliance between the two groups (Asymp. Sig. (2 tailed)\u0026thinsp;\u0026lt;\u0026thinsp;0.005). These findings highlighted the challenges of maintaining long term dietary interventions and emphasized the importance of variety in programs to ensure continued compliance.\u003c/p\u003e\u003cp\u003eTable 1 Baseline Characteristics of the Two Intervention Groups\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eParameters\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal (n[%)])\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTreatment (n[%])\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eControl (n[%])\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27[54]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15[60]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.395\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23[46]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10[40]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13[52]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAge (month)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14[28]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6[24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8[32]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u0026ndash;47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17[34]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5[20]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19[38]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7[28]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eBreastfeeding duration (month)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5[10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.894\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43[86]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21[84]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22[88]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eFirst complementary feeding (month)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1[2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.312\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49[98]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25[100]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eEducation of mother\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8[16]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5[20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.632\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJHS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15[30]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8[32]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7[28]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26[52]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14[56]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma/Bachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1[2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDead\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eEducation of father\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10[20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6[24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4[16]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e0.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJHS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12[24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5[20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7[14]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSHS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25[50]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13[52]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiploma/Bachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDead\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eOccupation of mother\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHousewife\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45[90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23[92]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22[88]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate Employee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTeacher/Lecturer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1[2]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eOccupation of father\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDead/Unemployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e0.940\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5[10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLaborer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27[54]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14[56]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13[52]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDriver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrivate Employee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7[14]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4[16]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEntrepreneur\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5[10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAge of mother (year)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47[94]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23[92]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAge of father (year)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35[70]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19[76]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16[64]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.630\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12[24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5[20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7[28]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDead\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eMother was the caregiver\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47[94]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23[92]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3[6]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eFather lives with the family\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45[90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21[84]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5[10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4[16]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eNumber of 6- to 59-month-old siblings -excluding he/she- (child)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45[90]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23[92]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22[88]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.637\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5[10]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2[8]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3[12]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0[0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eFrequency of main meals per day (times)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14[28]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6[24]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8[32]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36[72]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19[76]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17[68]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eFrequency of snack per day (times)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26[52]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14[56]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12[48]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.571\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24[48]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11[44]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13[52]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eAvailability of bathroom in the house\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAvailable\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24[96]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot Available\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1[4]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eES\u0026thinsp;=\u0026thinsp;Elementary School, JHS\u0026thinsp;=\u0026thinsp;Junior High School, SHS\u0026thinsp;=\u0026thinsp;Senior High School\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003e*Chi-Square Test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eGrowth Indicators\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA statistical analysis for each growth indicator was conducted to determine if the intervention caused a significant change between intervention and control group. Prior to this, a normality test was performed using SPSS v.29 software to confirm that the data was adhered to a distribution. Subsequently, a paired sample T-test was carried out also using SPSS v.29 software with the findings presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Moreover, Cohen's d was computed to quantify the effect size, indicating the magnitude of the difference between the two groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eChanges in growth indicators after 12-weeks intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eIndicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eBefore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eAfter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMean Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003e95% CI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003ep- value\u003c/em\u003e*\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eCohen\u0026rsquo;s d\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eAverage\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003eAverage\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003eLower\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003eUpper\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.764\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.931\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.597\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.87\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.820\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.961\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.679\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.020\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-2.310\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-1.730\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.612\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-1.833\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-1.392\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e3.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMUAC (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.467\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.547\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.398\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.364\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.417\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.311\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e2.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWAZ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.146\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.289\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-1.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-1.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.212\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.394\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHAZ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-2.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.121\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.048\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-2.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-2.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-0.066\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWHZ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.278\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.511\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e-0.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.440\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-0.607\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.273\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e1.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCI: Confidence Interval, MUAC\u0026thinsp;=\u0026thinsp;mid-upper arm circumference, WAZ\u0026thinsp;=\u0026thinsp;weight-for-age z-scores, HAZ\u0026thinsp;=\u0026thinsp;height-for-age z-scores, WHZ\u0026thinsp;=\u0026thinsp;weight-for-height z-scores.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e*Paired Sample T-Test\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, there was a positive change (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in various growth indicators for the both groups after a period of twelve weeks. Based on Cohen's d value, the effect size indicated a moderate to large difference between the two groups, indicating the substantial impact on growth outcomes. Both groups experienced substantial weight gain, with the intervention group showing an average increase of 0.764 kg (95% CI: -0.931 to -0.597, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the control group a slightly higher increase of 0.82 kg (95% CI: -0.961 to -0.679, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). These changes were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) with large effect sizes according to Cohen's d, though the control group had a slightly higher effect (2.4 vs 1.87). Linear growth also showed positive trends, with the intervention group increasing by an average of 2.02 cm (95% CI: -2.31 to -1.73, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the control group by 1.61 cm (95% CI: -1.833 to -1.392, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The effect on height was substantial in both groups, with Cohen's d exceeding 2.8. MUAC indicator also improved with the intervention group increasing by 0.467 cm (95% CI: -0.547 to -0.398, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the control group by 0.364 cm (95% CI: -0.417 to -0.311, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), both with large effect sizes (2.42 vs 2.88).\u003c/p\u003e\u003cp\u003eA moderate effect of WAZ was noted from intervention group with a Cohens\u0026rsquo; d value of 0.42. However, only a small effect of WAZ was observed from the control group with a Cohen\u0026rsquo;s d value of 0.28. Interestingly, a large effect of HAZ was recorded from the intervention group with a Cohens\u0026rsquo; d value of 0.69, but the control group showed no significant change. WHZ in the control group exhibited a greater increase and a large effect (Cohen\u0026rsquo;s d 1.09) compared to a moderate effect in the intervention group (Cohen\u0026rsquo;s d 0.49). This may indicate that children in the control group experienced a rapid weight gain without corresponding height growth, which resulted higher WHZ scores.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImpact of Compliance Rates on Nutritional Status Changes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTo gain more insight into the relationship between intervention compliance and nutritional status, the changes in growth indicators in the two groups during the course of the trial were analysed. Figures\u0026nbsp;3 and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e illustrated the relationship between compliance rates (%) and changes in nutritional status for the intervention and control groups, respectively. As shown in Fig.\u0026nbsp;3, the compliance rate of the intervention group was 73% in the first month, with a negative relationship with WAZ (-0.06), but a positive relationship with HAZ (0.04) and WHZ (0.01). This means that while compliance to the protein-rich biscuit intake was relatively high, improvements in nutritional status, particularly in WAZ and WHZ, were not yet significant, possibly due to an initial adaptation period. In the second month, the compliance rate dropped to 63% but showed a positive relationship with all z-score indicators: WAZ (0.10), HAZ (0.04), and WHZ (0.13). This indicated better improvements in nutritional status as children's bodies began to adjust to the intervention. By the third month, compliance rate further declined to 55%, yet the positive relationship with WAZ (0.12), HAZ (0.05), and WHZ (0.10) persisted, suggesting that nutritional status continued to improve despite lower compliance.\u003c/p\u003e\u003cp\u003e\u003cb\u003eFigure 3.\u003c/b\u003e Compliance Rates vs Nutritional Status Changes in the Treatment Group (WAZ\u0026thinsp;=\u0026thinsp;Weight-for-age z-score, HAZ\u0026thinsp;=\u0026thinsp;Height-for-age z-score, WHZ\u0026thinsp;=\u0026thinsp;Weight-for-height z-score)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, there were positive changes in nutritional indicators over 3 months along with consistently high rates of compliance exhibited by the control group. In the first month, the compliance rate stood at 99% with improvements noted in WAZ, WHZ and HAZ. In the second month, the compliance rate was slightly decreased to 94%, but WAZ increased (0.06) and WHZ decreased to 0.08 while HAZ persisted. The third month showed a major improvement in WHZ by 0.196, a minor fall in HAZ (-0.03), a slight increase in WAZ (0.10), with compliance rate of 97%. These differences in growth measures despite of compliance rate fluctuations suggest complex linkages between food intake and growth trends in the control group during the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAdditional Protein Intake Contribution to Anthropometric and Nutritional Changes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe effects of protein consumption on anthropometry and nutritional status of stunted children were shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. This analysis of anthropometry and nutritional status aimed to evaluate how efficiently protein from both sources was utilized by the body for growth in both groups.\u003c/p\u003e\u003cp\u003eThe treatment group had an average compliance rate of 64% (SD\u0026thinsp;=\u0026thinsp;7%), resulting in an average additional daily protein intake of 10.24 grams (SD\u0026thinsp;=\u0026thinsp;1.18). Over 30 days, this group consumed a total of 307.2 grams of additional protein (SD\u0026thinsp;=\u0026thinsp;35.3). In contrast, the control group exhibited a higher compliance rate of 97% (SD\u0026thinsp;=\u0026thinsp;2%), with an average daily protein intake of 15.47 grams (SD\u0026thinsp;=\u0026thinsp;0.33), accumulating to 464.0 grams of additional protein over 30 days (SD\u0026thinsp;=\u0026thinsp;9.86). The significance of the groups differences was assessed using the independent sample t-test, and for these indicators showed statistically significant differences between the treatment and control groups with the same values (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eThe analyses of weight gain per gram of protein consumed in the treatment group discovered that the treatment group achieved a higher efficiency, with a weight gain of 0.9 grams per gram of protein consumed (SD\u0026thinsp;=\u0026thinsp;0.3). Conversely, the control group showed a lower weight gain of 0.6 grams per gram of protein (SD\u0026thinsp;=\u0026thinsp;0.1). The siginificant test indicated that this difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For height improvement, the treatment group exhibited an increase of 0.0022 cm per gram of protein (SD\u0026thinsp;=\u0026thinsp;0.0004), while the control group had a smaller height gain of 0.0012 cm per gram of protein (SD\u0026thinsp;=\u0026thinsp;0.0002). A significant difference also found between the groups for this indicators (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProtein Intake Contribution to Anthropometric and Nutritional Changes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicators\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eScore\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAverage of compliance rates (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAverage of additional protein intake per day (g)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAverage of additional protein intake after 3 months (g)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e307.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e464.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWeight gain per gram protein (g)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.028\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHeight gain per gram protein (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0022\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0012\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMUAC gain per gram protein (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0005\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.178\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWAZ gain per gram protein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.033\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHAZ gain per gram protein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.020\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWHZ gain per gram protein\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0002\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.0003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation, MUAC\u0026thinsp;=\u0026thinsp;mid-upper arm circumference, WAZ\u0026thinsp;=\u0026thinsp;weight-for-age z-scores, HAZ\u0026thinsp;=\u0026thinsp;height-for-age z-scores, WHZ\u0026thinsp;=\u0026thinsp;weight-for-height z-scores.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e*Independent Sample T-Test\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe treatment group had higher MUAC gain per gram of protein showing an increase of 0.0005 cm (SD\u0026thinsp;=\u0026thinsp;0.0002) as compared to 0.0003 cm (SD\u0026thinsp;=\u0026thinsp;0.0000) in the control group, but this slight difference was not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). For WAZ gain per gram of protein the treatment group showed 0.0003 (SD\u0026thinsp;=\u0026thinsp;0.0001) while the control group had 0.0002 (SD\u0026thinsp;=\u0026thinsp;0.0000), which was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The HAZ of the treatment group was 0.0001 (SD\u0026thinsp;=\u0026thinsp;0.0000), and no improvement was observed in the control group (0.0000, SD\u0026thinsp;=\u0026thinsp;0.0000), with the difference was found statistically significant (p\u0026thinsp;=\u0026thinsp;0.020). Nevertheless, both groups showed equal improvements in WHZ per gram of protein, with a gain of 0.0003 in the treatment group (SD\u0026thinsp;=\u0026thinsp;0.0002) and 0.0003 in the control group (SD\u0026thinsp;=\u0026thinsp;0.0001), also this change was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"5. Discussion","content":"\u003cp\u003eOur study in Garut Regency, West Java, shows some promising results for using protein-rich biscuits to promote the growth of stunted children aged 24\u0026ndash;59 months. Over 3 months, some improvements in growth indicators for both groups were noted, but there were some interesting differences worth discussing.\u003c/p\u003e\u003cp\u003eInterestingly, despite lower compliance (64% vs. 97%) and consequently lower overall protein intake in the treatment group, the children demonstrated more efficient protein utilization. For example, the HAZ of treatment group was improved from \u0026minus;\u0026thinsp;2.43 to -2.30, with a substantial effect size (Cohen's d\u0026thinsp;=\u0026thinsp;0.69), indicating progress in addressing stunting. However, it is important to address that these children remained clinically stunted (z-score \u0026lt; -2 SD), underscoring the persistent nature of this condition. In contrast, the HAZ of control group remained unchanged at -2.45 (Cohen's d\u0026thinsp;=\u0026thinsp;0.02).\u003c/p\u003e\u003cp\u003eThe protein from the biscuits appeared to contribute more effectively to growth parameters. For example, the treatment group showed greater increases in body weight (0.9 g vs. 0.6 g) and height (0.0022 cm vs. 0.0012 cm) for each gram of protein consumed as compared to the control group. This suggests that the protein-rich biscuits may have enhanced bioavailability or have been better suited for supporting growth in stunted children than other protein from local sources.\u003c/p\u003e\u003cp\u003eMoreover, protein quality can also be improved by performing thermal heating in the process of biscuits production which leads to the aggregation of protein, resulting in decreased protein solubility. The sensitivity of protein to the heating process can be harnessed to modify its properties (Andoyo et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In this case, specifically denaturing the protein can enhance the digestibility of protein. The digestibility of protein in the body provides an indication of the quality of the protein consumed. The easier a protein to digest in the body, the higher the quality of the protein (Adhikari et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ketnawa \u0026amp; Ogawa, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) .\u003c/p\u003e\u003cp\u003eThe treatment group exhibited superior improvements in MUAC per gram of protein (0.0005 cm vs. 0.0003 cm), indicating more effective enhancement of muscle mass and overall nutritional status. The more pronounced gains in WAZ and HAZ per gram of protein in the treatment group further emphasized the enhanced growth outcomes associated with the feeding of protein-rich biscuits.\u003c/p\u003e\u003cp\u003eThese findings are consistent with previous research highlighing the effectiveness of soy-based nutritional interventions in improving the growth and nutritional status of malnourished children. For example, the children in Hanoi, Vietnam with severe acute malnutrition who consumed soy and mung bean-based ready-to-use therapeutic food (RUTF) (15% protein per 100 grams) showed significant improvements in nutritional status after four weeks. The children were reported to show an average weight gain of 0.64 kg, height increases of 0.7 cm, and improvements in WAZ, HAZ, and WHZ scores (Nga et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Furthermore, soy-based lipid nutrient supplements (LNS) were provided to infants in rural Malawi and the results showed that infants who received soy-LNS had a slight decrease in the incidence of severe stunting (9.1%) (Mangani et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Similarly, research conducted in Tehran, Iran, demonstrated that children with mild to moderate malnutrition who received a local ready-to-use supplementary food (RUSF) containing soy protein isolate for eight weeks experienced significant increases in body weight and body mass index as compared to a control group on a normal diet (Azimi et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn intervention in Luapala, Zambia, where stunted and underweight children were fed soy-corn porridge (13.5% protein per 100 grams) over a 12-month period, produced notable increases in height and weight, adding more evidence to this picture (Masuda \u0026amp; Chitundu, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Furthermore, a study reported that malnourished children in Dhaka, Bangladesh, gained an average of 3.9 (\u0026plusmn;\u0026thinsp;3.2) kg over the course of four months when they were fed soy-based RUTF and containing 14.5% protein (Hossain et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Similarly, a study found that children who were given soy-corn porridge containing 15% protein for 12 days and were classified as moderately or severely malnourished gained an average body weight of 35.45 g per day (Lal\u0026egrave;y\u0026egrave; et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It was also shown that children with acute malnutrition in Bogor, Indonesia, who received soy-based RUTF for eight weeks gained more than 2 g/kg/day of body weight in comparison with other RUTF (Rachmadewi et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These consistencies across studies strengthen the evidence for protein-rich interventions in addressing child malnutrition.\u003c/p\u003e\u003cp\u003eThe beneficial effects of the protein-rich biscuit intervention on the nutritional status and growth of stunted children emphasize the need for not only consuming adequate protein, but also the quality and bioavailability of that protein. The treatment group exhibited better growth outcomes than the control group, with notable improvements in HAZ and higher protein utilization efficiency. These findings raise the possibility that the children's bodies were able to absorb and utilize the modified protein in the biscuits more efficiently. This result was consistent with a recent study on cookies enriched with 20% soymeal flour, which also showed the best results in terms of antioxidant and nutritional qualities. These fortified cookies had higher calcium and iron content, enhanced organoleptic qualities, and increased total soluble phenolic contents, contributing to stronger antioxidant capacities and greater health benefits (Ghoshal \u0026amp; Kaushik, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The effectiveness of the soy protein-based products emphasizes how crucial it is to include high-quality, bioavailable protein sources in nutritional treatments, especially for vulnerable groups like stunted children (Endrinikapoulos et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eThis improved use of protein can be partially ascribed to the biscuit production process, specifically the pre-heating stage. During pre-heating, the proteins in the raw materials undergo denaturation, a process that disrupts hydrogen bonds and hydrophobic interactions, leading to changes in protein structure (Damodaran \u0026amp; Paraf, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Kelleher et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These changes, while initially causing protein aggregation, ultimately result in a more open and accessible structure that can improve the digestibility of the protein (Andoyo et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Fetriyuna, Lutfiah, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). A study dicovered that thermal processing greatly increase the digestibility of soy protein isolate (SPI) and increases the bioavailability of protein in diets based on soy (Pereira et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFor stunted children, who often face challenges in nutrient absorption, the denatured protein in the biscuits may be more easily broken down by digestive enzymes, increasing the bioavailability of essential amino acids crucial for growth. This improved digestibility is linked to a higher Protein Efficiency Ratio (PER), which measures the protein's ability to support growth (Huangfu et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Smolin et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A study showed that the digestibility of amino acids in stunted children improves significantly after the heat and pressure processing of plant proteins, which inactivates trypsin inhibitors while retaining essential amino acids like lysine and proline (Devi et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; S\u0026aacute; et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe fact that each gram of protein in the treatment group contributed more to weight gain and height increase compared to the control group underscores the effectiveness of the modified soy protein in the biscuits. Furthermore, the process of denaturation and subsequent protein modification not only improved digestibility but also likely inactivated anti-nutritional factors such as trypsin inhibitors, which are known to interfere with protein digestion. The retention of essential amino acids, such as lysine and proline, during the biscuit-making process would have further contributed to the improved growth parameters observed in the treatment group (Amigo \u0026amp; Hern\u0026aacute;ndez-Ledesma, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Devi et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Fetriyuna, Lutfiah, et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Fortified soy-based foods also can further enhance these nutritional benefits by adding additional vitamins and minerals as a potential growth booster in stunted children (Endrinikapoulos et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations of the Study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIt is imperative to acknowledge the importance of a varied diet and micronutrient intake although the current study mainly focused on the effect of protein-rich biscuits to the stunted children. This is because meals rich in many vitamins and minerals are also key to physiological growth and development. For instance, micronutrients like zinc, iron and vitamin A are known to be growth promoters. Future studies could look into the interaction between protein and micronutrient sufficiency to get a better understanding of dietary strategies for stunting. Moreover, the present study did not exclude children with mild or acute illnesses, and it did not incorporate a 24-hour dietary recall to capture the overall dietary intake, as the primary objective was to assess the effect of protein-rich biscuits as a supplementary intervention. These unmeasured variables may have influenced the findings. Therefore, future studies should take these variables into considerations to provide a more complete picture of protein rich interventions and stunting.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe protein-rich biscuit intervention had a potential and positive impact of controlling nutritional status of stunted children, particularly in HAZ. Significant anthropometric improvements and improved protein utilization were noted in the therapy group despite decreased compliance. It is important to highlight that both quantity and quality of protein are considered in addressing stunting. In this regard, the pre-heating process in the production of protein-rich biscuits plays a crucial role in enhancing the bioavailability of protein, thereby making it more effective in supporting the growth and nutritional mitigation of stunted children. However, limitations such as exclusion of children with mild and acute illness and 24-h food recall method could have impacted the outcomes. Future research should look into long term effect and scalability of the intervention, protein-micronutrient interaction and non-nutritional factors to better understand and address stunting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Research Ethics Committee of Universitas Padjadjaran, Bandung. The approval was granted under the reference number 280/UN6.KEP/EC/2024. All research procedures were conducted in accordance with the ethical standards set forth by this committee and adhered to the principles of the Declaration of Helsinki. Clinical trial number:\u0026nbsp;INA-1909202525BA66D.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents or legal guardians of all participating children prior to enrollment. Participants' confidentiality and anonymity were strictly maintained throughout the study. The study did not involve the collection or use of any personally identifiable data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eProgram Riset Kolaborasi Indonesia (Indonesia Collaborative Research Program).\u003c/p\u003e\n\u003cp\u003eAUTHOR CONTRIBUTION\u003c/p\u003e\n\u003cp\u003eUII was responsible for field data collection related to the intervention, including \u0026nbsp;coordinated the biscuit production process and ensured timely delivery of both the soy-based biscuits and standard protein foods to the study sites, also handled all necessary permit processes with local authorities. In addition, she contributed to the statistical analysis and was a major contributor in drafting the manuscript.\u003c/p\u003e\n\u003cp\u003eFF supervised the field activities and conducted community coordination, including providing nutrition education to caregivers and engaging with local stakeholders such as health workers and health centre staff. She also contributed to validation and provided material, literature and technical support.\u003c/p\u003e\n\u003cp\u003eSNF, a medical doctor specializing in clinical nutrition, served as a consultant throughout the intervention phase, advising on study execution and troubleshooting field challenges. She also contributed to the ethical clearance process, revised the manuscript with a focus on interpreting intervention outcomes, and ensured coherence in evaluating the findings.\u003c/p\u003e\n\u003cp\u003eAMS provided input and suggestions on the presentation of the results, including tables and figures. He also participated in technical writing, editing for language clarity, and enhancing the overall presentation of the study's findings.\u003c/p\u003e\n\u003cp\u003eRA conceptualized and designed the study, including the laboratory trial and formulation of the soy-based biscuits, and supervised the industrial-scale production. He oversaw the implementation of the intervention in the study communities, critically revised the manuscript for important intellectual content, and secured funding for the study.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003eAdhikari, S., Schop, M., de Boer, I. J. M., \u0026amp; Huppertz, T. (2022). Protein Quality in Perspective: A Review of Protein Quality Metrics and Their Applications. In \u003cem\u003eNutrients\u003c/em\u003e (Vol. 14, Issue 5). MDPI. https://doi.org/10.3390/nu14050947\u003c/p\u003e\n\u003cp\u003eAmigo, L., \u0026amp; Hernández-Ledesma, B. 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American Academy of Pediatrics. https://doi.org/10.1542/peds.2014-3111\u003c/p\u003e\n\u003cp\u003eSutrisno, A., Suloi, A. N. F., Murtini, E. S., \u0026amp; Bahmid, N. A. (2024). The effect of corn starch and transglutaminase on quality improvement of soybean-based analog rice. \u003cem\u003eFuture Foods\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e. https://doi.org/10.1016/j.fufo.2024.100407\u003c/p\u003e\n\u003cp\u003eWorld Health organization (WHO). (2014). \u003cem\u003eGlobal Nutrition Targets 2025 Stunting Policy Brief\u003c/em\u003e. https://iris.who.int/bitstream/handle/10665/149019/WHO_NMH_NHD_14.3_eng.pdf?sequence=1\u003c/p\u003e\n\u003cp\u003eWorld Health Organization (WHO). (2017). \u003cem\u003eGuideline: Assessing and Managing Children at Primary Health-care Facilities to Prevent Overweight and Obesity in the Context of the Double Burden of Malnutrition (Updates for the Integrated Management of Childhood Illness (IMCI))\u003c/em\u003e. WHO.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Child growth, dietary protein, food, nutritional status, randomised controlled trial, soy protein, stunting","lastPublishedDoi":"10.21203/rs.3.rs-7998940/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7998940/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA minute reduction in stunting rates from 21.6% in 2022 to 21.5% in 2023 called for more innovative strategies to address stunting in Indonesia. One such approach involves dietary supplementation with high-quality protein, which is essential for catch-up growth in stunted children. This study evaluated a 3-months intervention using protein-rich biscuits on the growth and nutritional status of stunted children aged 24\u0026ndash;59 months in Garut Regency, West Java. The intervention group (30 children) consumed 10 pieces of high-protein biscuits (100 g/day, 16% protein), while the control group (25 children) received equivalent protein from eggs, tofu, and tempeh. The primary objective was to assess changes in height-for-age z-scores (HAZ), along with secondary outcomes like mid-upper arm circumference (MUAC), weight, height, weight-for-age (WAZ), and weight-for-height (WHZ). Results showed a significant improvement in HAZ for the intervention group (from \u0026minus;\u0026thinsp;2.43 to -2.30; Cohen's d\u0026thinsp;=\u0026thinsp;0.69), while the control group saw no significant change (HAZ remained at -2.45; Cohen's d\u0026thinsp;=\u0026thinsp;0.02). Additionally, the intervention group had greater gains in weight, height, and MUAC per gram of protein consumed, suggesting more efficient protein utilization. The results suggest that protein-rich biscuits using heat-treated soy protein concentrate could enhance protein bioavailability and digestibility.\u003c/p\u003e","manuscriptTitle":"Efficacy of Protein-Rich Soy Biscuits on Growth Parameters of Stunted Children in West Java, Indonesia: A Randomised Controlled Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-04 10:54:26","doi":"10.21203/rs.3.rs-7998940/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95052db7-c254-4052-9ee1-8978a3cff916","owner":[],"postedDate":"December 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59077682,"name":"Biological sciences/Biochemistry"},{"id":59077683,"name":"Health sciences/Diseases"},{"id":59077684,"name":"Health sciences/Health care"},{"id":59077685,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-04T12:41:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-04 10:54:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7998940","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7998940","identity":"rs-7998940","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}