What Does Stunting Look Like in Indonesia?

One-third of Indonesian children (over 7 million) under the age of five are found to suffer from stunting, which is a condition where their height is lower than the standard height for their age. This makes Indonesia to have the fifth-highest level of stunting in the world and in this region, stunting is the most common form of malnutrition that is found since birth.

Now let’s look at a real life example of what stunting in children can look like in Indonesia…

Two 32-month-old twin girls named Zahra and Zohra, living in a village called Pandes, Indonesia were born prematurely and they weighed 1.6 and 2.1 kg, respectively. They have continued to struggle to get to a healthy weight even to this day. In these girls’ case, the lack of breastfeeding contributed to their stunting and poor nutrition. When the twins were four months old, their father was hospitalized for over a month after being in a serious motorcycle accident and was unable to work for the next six months. With the burden of this situation and trying to take care of her prematurely born twins, the mother stopped breastfeeding the twin girls. Instead, she fed them with formula milk and the twins still fail to meet the weight and height expectations for their age and continue to remain underweight.

It has been shown that breastfeeding is critical in addressing all forms of malnutrition and protects children from being stunted. UNICEF recommends exclusive breastfeeding up until the age of six months and to then continue with breast-feeding supplementary food. Breast milk has sufficient nutrients for babies, so the mother essentially does not need to feed their baby anything else for the first six months. Additionally, the amount of breast-feeding in Indonesia is not nearly as high as it should be at only 54.3% nationally. Breastfeeding, however, is not the only factor associated with stunting, and is just one of the factors that we will focus on in this post.

Children who are stunted are also faced with various consequences later on in life. Stunted children are found to have a lower productivity rate by 20% than children who don’t suffer from stunting. Stunting during early childhood can also lead to higher risks for chronic diseases, delayed cognitive development and reduced academic achievement in the future.

Now, so stunting in children seems like a pretty big issue in Indonesia right? What is the government and the health system doing about it though? Can this burden on the country go on?

Fortunately the government of Indonesia has been piloting a multi-dimensional approach to address the stunting problem. It aims to improve awareness about feeding practices and the prevention of illness, as well as the access to necessary health care services and proper nutrition. However, as you can see, the problem is still very great, especially with the vast number of children still suffering from stunting, and there needs to be more done about the issue because it has only recently been addressed. What are some other ways that can help Indonesia combat stunting in children?

Written by Hannah Jin

Early Successes in Indonesia’s Fight Against Stunting. (n.d.). Retrieved December 05, 2016, from https://www.mcc.gov/our-impact/story/story-early-successes-in-indonesias-fight-against-stunting

McAuliffe, A. (2016, March 28). Double burden: Childhood stunting and obesity in Indonesia – UNICEF East Asia & Pacific. Retrieved December 05, 2016, from https://blogs.unicef.org/east-asia-pacific/double-crisis-the-dual-burden-of-stunting-and-obesity-in-indonesia/

Hungry behavior

Today, malnutrition is becoming an epidemic. It has a huge effect on the population’s health.  Logically, social outcomes are huge too.  Because we all know: When we’re hungry.. we are not at our best mood.

The effect of malnutrition already starts before birth.  Pregnant women that are suffering from malnutrition tend to have children with behavioral problems later in life. Prenatal malnutrition leads to children with less playful behaviour, whether the children are being malnourished or not. But: Malnourished mothers are more likely to have underweight children. These children will in turn have a higher risk of physical and cognitive impairment. This contributes to the cycle of poverty, because if children do not function well socially, they are less able to work, contribute to local economies, and provide care for their families later in life.

Increased aggressive behavior seems to be a relatively large social consequence of being overweight and malnourished. A high sugar diet seems connected with a high level of hyperactivity within children’s behaviour, while undernourished and underweight children on the other hand show more apathic and nonactive behavior. Malnourished children are known to be less social and less interested in having social relationships with their peers.

The absence of secure relationships can affect physical security. Not having good social relationships in child- and adulthood can result in not feeling safe at home(being shut out) and eventually in feelings of anxiety. Malnutrition thereby is known to cause  people to be at risk for staying single. Obese women have more trouble finding a sexual partner than normal-weight women. Also, these women tend to be at risk for getting pregnant unplanned. On the other hand, being married and malnourished causes people to be less happy in the marriage. This can trigger depression, distorted body image and low self-esteem, which can be a real problem in marriage or other social relationship.

Besides that, malnutrition causes other behavior problems. Bullying, but also being bullied are social outcomes that can affect the population.  One possible, but so far untested, hypothesis is that early malnutrition predisposes to antisocial behavior because malnutrition affects neurocognitive functioning. Considered is that malnutrition slows down the process of learning how to make rational decisions.  This makes malnourished children and adolescents even more sensitive. They are also much more influenced by “emotional context”.  Besides, they seem to be even more sensitive to the advertising of advertising of food than people that do not suffer from malnutrition, and in particular to the large amount of junk food available in Indonesia.

There also seems to be a trend in weight and socio-emotional- and behavioral problems. Bullying, but also being bullied can make people feel excluded or shut out and lonely. The more you weigh, more problems appear. Also, the chance of having anxiety and depressive feelings is growing. The same effects are happening with being underweight. These effects not only have impacts on the social life, but you can imagine that it also has impacts on the behavior at school and work too.

As you can see by building up our blog, the facts of the problems linked and caused by malnutrition in Indonesia are adding up. This growing problem affects all kinds of aspects of the life of the Indonesian population. We hope this makes clear that it must really be a priority in Indonesia to address this double burden of disease.

Written by Eline

sources:

Hernandes AS, Almeida SS. Postnatal Protein Malnutrition Affects Inhibitory Avoidance and Risk Assessment Behaviors in Two Models of Anxiety in Rats. 2013. Pp. 213-219

Liu, J., Raine, A., Venables, P. H., & Mednick, S. A. (2004). Malnutrition at age 3 years and externalizing behavior problems at ages 8, 11, and 17 years. American Journal of Psychiatry161(11), 2005-2013.

Almeida, S. D. S., Tonkiss, J., & Galler, J. R. (1996). Prenatal protein malnutrition affects the social interactions of juvenile rats. Physiology & behavior60(1), 197-201.

Wester M. (2006) Sociale aspecten van overgewicht bij kinderen.  Rijksuniversiteit Groningen. Available from http://www.ppsw.rug.nl/~veenstra/Supervision/Master/Wester.pdf

Seipel, M. M. (1999). Social consequences of malnutrition. Social Work44(5), 416-425.

More Than Just Skinny

When you think of malnutrition in Indonesia, what do you think of? What kind of image comes to mind? Probably some hungry child that is skinny to the bone, without any food to eat, right? Maybe similar to something that is portrayed in the image above. Before I was educated on this topic, I would’ve thought the same thing.

For many years now, the term “malnutrition” was used only to mean undernutrition, which means that an individual is not receiving the sufficient amount of food intake in their bodies. I personally was familiar with malnutrition as this definition for a long time as well. However, malnutrition actually refers to both the excess and deficiency in nutritional intake, or other words, undernutrition and over nutrition.

Indonesia is mainly referred to as a low, middle-income country, and they continue to struggle with combating malnutrition. With this said, there are many health outcomes and consequences that come with malnutrition in Indonesia. Many instances of malnutrition are seen in maternal and young child undernutrition in Indonesia especially during the infant period where the effects can be very severe and considerable. In childhood undernutrition, it is estimated that it is associated with 1/2- 1/3 of all global child deaths. The thing, however, is that these deaths aren’t just results of undernutrition, but because of the variances of diseases that develop due to the lack of necessary nutrients for the human body. In this specific case, undernutrition contributes to child mortality is the highest for diarrheal diseases at around 73% and around 50% for pneumonia, measles, and severe neonatal infections. Because the child is not receiving the sufficient nutrients to live a healthy and active life, they are prone to developing different kinds of vitamin or micronutrient deficiencies like Vitamin A deficiency, which was commonly found in Indonesia. At least half of the population was considered to be suffering from a deficiency of at least one micronutrient. This can then also lead to stunting, or low height, especially within children. Stunting is a huge problem in Indonesia, which will be discussed in another post.

Anemia, or iron deficiency, is also associated with malnutrition in pregnant women, where it affects around 40% of that specific population. In urban areas, 20% of non-pregnant women over the age of 14, 13% of men, and 10% of children were found to be anemic. Iron deficiency still continues to be a serious problem in Indonesia mainly due to the level of consumption of salt or iodine.

With these deficiencies come even more diseases that are developed due to the fact that their bodies are not functioning to its potential and therefore is more prone to other physical complications. It’s mind-blowing how many more diseases that can connected to all of these deficiencies!

On the other hand, malnutrition can also mean over nutrition, where overweight or obesity can be developed. Obesity is associated with energy imbalance and is related to alternations in a person’s metabolic system. An individual may not be receiving the right variance of foods and may only be consuming foods high in fat, sugar, and salt, which then lead to overweight and obesity. This is usually found in adults and in individuals later on in life. Many non-communicable (NCDs), or long-term, diseases can be consequences of malnutrition in Indonesia. Some NCDs that are seen in the country are hypertension, diabetes, cancer, stroke, and ischemic heart disease.

In Indonesia, type 2 diabetes was also strongly associated with central obesity. It was found that 5.7% of the population over 15 years of age had diabetes and 10.2% of the population was pre-diabetic with an impaired glucose tolerance. In addition, as mentioned earlier, hypertension, is also prevalently seen in Indonesia. Hypertension is known as having high blood pressure and around 45.8% of men and 53.4% of women over the age of 45 have hypertension in Indonesia. It is in fact, worse in women than men, and it also increases considerably with age. Hypertension has been found to affect the majority of Indonesian adults over the age of 45, but only 40% of women and 20% of men had any knowledge of their own condition.

A big concern with all of these risks of developing these diseases associated with over nutrition is that the risks are that much more amplified across a person’s life course and even more increasingly over time. Which basically means that the health outcomes can get more and more severe with time, in the case of over nutrition and obesity.

As you can see, there is an innumerable number of diseases and deficiencies that are associated with malnutrition, both within undernutrition and over nutrition, in Indonesia. Who would’ve thought…

 

Written by Hannah

Caulfield, L.E., de Onis, M., Blössner M., Black, R.E.. (2004). Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr. 80(1):193-8.

Shrimpton R. and C. Rokx. (2013). The Double Burden of Malnutrition in Indonesia, World Bank Jakarta, Report 76192-ID. Retrieved from http://documents.worldbank.org/curated/en/955671468049836790/pdf/761920WP0P12640Box0379884B00PUBLIC0.pdf.

“Gemukness”

Gemukness: “Deliberately unspecific term meaning overweight/obesity but in the Indonesian context. Hidden fatness.”

Ever wonder what the Indonesians refer to overweight or obese? Well now you know that it is “gemukness” or “gemuk.”

Now why am I writing about obesity on a blog about malnutrition in Indonesia? Good question. Malnutrition actually incorporates both the aspect of undernutrition and overnutrition– and in this case, obesity is associated with overnutrition.

In Indonesia, undernutrition however is a huge issue and is given more of a priority compared to overweight and obesity, because these are believed to be problems of wealthier countries.

Obesity is not just a problem for the wealthy.

However, obesity is not just seen in wealthy, high income countries or regions of the world where people can afford lavish meals and can afford to eat 10 meals a day. It is true that obesity does in fact increase with income, but that doesn’t mean that lower wealth areas aren’t affected as well. It has been shown that in Indonesia, especially in the outer islands, the rates of adult overweight and obesity are of similar, if not greater, magnitude as undernutrition. In this specific area, the poverty rates are higher than the major cities of the country, and the problem of “gemukness” is actually a greater double burden than undernutrition. Poor nutrition in the younger years and in mothers continue to contribute to the increased risk of obesity later on in life among adults who survive the malnutrition as a child and then end up in environments where they are more prone to be caught in obesity.

Because of this “surprise,” obesity in Indonesia is even more of a problem because of it is a “hidden problem.” Many people are not fully aware of the consequences they are faced with in their particular environments.

The rate of gemuk adult men and women in Indonesia has been significantly increasing over the last few decades, while the rate of malnourished men and women has decreased considerably. This research and information was taken from the Indonesian Family Life Surveys, and it was additionally shown that the proportion of gemuk men and women, of a BMI of greater than 25, almost doubled, and that the greatest increase was found in obese women. We see that undernutrition is actually declining, while overweight and obesity is increasing in Indonesian adults and the risks increase with age.

Of course, genetics was also tested and researched, just to see if it played even a slight role in the gemukness issue. But researchers were left to find that there is no absolute evidence that genetics plays a role in the growing problem of obesity. Rather, it has been found that the obesity problem is mainly caused by consequences seen during childhood like stunting and constrained fetal growth.

On the other hand, in more areas of the country where income increased, food consumption patterns seemed to suggest increased food intake which contributed to obesity in many people. The greatest increase in food intake was found from meat, fish and eggs, and in prepared foods, where the rates were nearly doubled! Indonesian people be eating lots of animal products!… and processed foods… However, with the scenario with processed foods, many people in low income areas of Indonesia are found to consume more processed foods because they are more affordable than food, say, compared to a farmers market with organic fruits and vegetables. With this said, many of these Indonesian people are found eating instant noodles instead of a good, healthy meal, just because they simply cannot afford it. Instant noodles are good and all, but the constant consumption of these cups of deliciousness are not beneficial for anyone’s health.

And on top of that, much of the physical and built environments in Indonesia are not very friendly in terms of encouraging physical exercise. Instead of bike lanes, pedestrian sidewalks, and parks, there are many many streets where processed foods are sold. Many of the school children purchase snacks from these street vendors and shops, but they do not get the right exercise to burn off the excessive snack consumption.

While undernutrition is a big issue in Indonesia, Gemukness, or obesity, is also just as big of an issue in this region of the world.

Now the questions we are left with are — What other consequences come from obesity? What do we do about it? How can we fix it?… After researching and studying about the obesity problem in Indonesia, I personally believe that one practical way to help control the problem is to continue to educate the people of Indonesia about the extent of the problem and how to change their lifestyle and diet to reduce the risks. This is due to the fact that many Indonesians are not even aware of the severity of the obesity issue in the country!

Written by Hannah

Shrimpton R., & C. Rokx. (2013). The Double Burden of Malnutrition in Indonesia, World Bank Jakarta, Report 76192-ID. Retrieved from http://documents.worldbank.org/curated/en/955671468049836790/pdf/761920WP0P12640Box0379884B00PUBLIC0.pdf.

Malnutrition Stresses our Brain Out

Malnutrition can make us stressed!

This may seem like a random statement, but there is a lot of truth in it unfortunately. Malnutrition therefore does not only have physical impacts but maybe even bigger impacts on our mental state. During childhood, malnutrition can have major impacts on life and can even  lead to impairments in the future, related to mental stress.

Children that are undernourished and have deficiencies in their micro- and macro nutrients have an impaired intellectual capacity. Long term, or really severe malnutrition limits brain growth and may result in mental retardation, which affects the ability of both cognitive and mental functioning, which may lead to the inability to learn and perform daily tasks of living. Thereby, Malnourished children lack energy, so they become less curious and playful and communicate less with the people around them, which impairs their physical, mental and cognitive development, such as decreases in IQ, reading, arithmetic, reasoning, vocabulary, verbal analogies, visual-spatial working memory, simple and complex auditory working memory, sustained attention and information processing.  You may understand that this has a major impact on the lives of these children. It can determine whether they will be able to have a good education and job, which sets their future to be rather uncertain.  

Besides the effects on the child’s developing brain, malnutrition can even have these effects on adults: They have potential risks of long-term effects included impaired cognitive performance. The facts are there! According to a study performed in  2010 in the journal “Social Science & Medicine.” Dr. Zhenmei Zhang and her fellow researchers , adult men who were undernourished during childhood had a 29 percent greater risk of having cognitive impairment after age 65. For women, this number was even higher, namely 35%.

Some other important negative effects of being undernourished are the increased responses to stress and an increased risk of schizophrenia, anxiety and depression. This states for both adults as for children. Chronic or extreme hunger and energy lacks have impacts on mood and responsiveness of the brain, resulting in apathetic, sad, and hopeless feelings. Essential brain functions, hormonal levels, nutrient provision in the brain, the ability to fight infections and other functions that affect the brain are strongly deprived.

On the other hand, high intakes of fats and sugar play a huge role in mental health and emotional state, because it really affects hormone and neurotransmitter levels in the brain too.  High cholesterol and fatty diets may cause clotting in the brain and cause strokes. And then we are not even speaking about the effect of alcohol and tobacco, which have major destroying consequences on the brain nerves. Thereby, it interferes with sleep patterns, which can cause mood swings and rises the risks of developing depression, anxiety and aggressive behavior too.

Undernourishment of pregnant women may have the same effect on the children that they give birth to. So malnutrition does not only have effects on the person itself, but on the mental health of the next generation too. Many malnourished mothers are unable to provide psychosocial stimulation to their children during food crises due to their own poor physical or mental health. A lack of psychosocial stimulation has adverse consequences for children’s development (cognitive, motor, language) and mental health.Recently, the male offspring of nutritionally deprived pregnant women were found to have 2.5 times the normal rate of antisocial personality disorder in adulthood

I think these facts makes it even more clear: Malnutrition, whether being under- or overweight, may have major impacts on everyday life. It is a precaution for an impaired mental health and mental diseases like depression and anxiety. Having a good diet from birth to death therefor is the basis of a good working brain and a healthy mental state. One more reason to address the malnutrition problem!!

Written by Eline

sources:

Jeffery, Douglas R., M.D., Ph.D. “Nutrition and Diseases of the Nervous System.” In Modern Nutrition in Health and Disease. 9th edition. Edited by Maurice E. Shils, M.D., Sc.D., James A. Olson, Ph.D., Moshe Shike, M.D., and A. Catharine Ross, Ph.D. Baltimore: Williams and Wilkins, 1999.

Katz, David L., M.D., M.P.H. Nutrition in Clinical Practice. New York: Lippincott, Williams, and Wilkins, 2001.

Shiveley, LeeAnn R., M.P.H, R.D. and Patrick J. Connolly, M.D. “Medical Nutrition Therapy for Neurologic Disorders.” In Krause’s Food, Nutrition, & Diet Therapy. 10th edition. Edited by L. Kathleen Mahan, M.S., R.D.,C.D.E., and Sylvia Escott-Stump, M.A., R.D., L.D.N. New York: W. B. Saunders Company, 2000.

Westermarck T., M.D., D.Sc. and E. Antila, M.D., Ph.D. “Diet in Relation to the Nervous System.” In Human Nutrition and Dietetics. 10th edition. Edited by J. S. Garrow, M.D., Ph.D., W. P. T. James, M.D., S.Sc., and A. Ralph, Ph.D. New York: Churchill Livingstone, 2000.

http://www.minddisorders.com/Kau-Nu/Nutrition-and-mental-health.html#ixzz4PtDy01yu

American Dietetic Association. 216 West Jackson Boulevard, Chicago, Illinois, 60606-6995. <http://www.eatright.org> .