The Triple Burden of Malnutrition Among Adolescents in Indonesia

Abstract

Background:

Indonesia is a prime example of the triple burden of malnutrition. Indonesian adolescents are among the hardest hit, with approximately one in four adolescent girls suffering from anemia, while nearly one in seven adolescents is overweight or obese.

Objectives:

The present editorial provides a snapshot of the various research papers included in this Supplement, which calls for increased attention to adolescent nutrition in Indonesia and beyond.

Results:

Despite major steps to reduce undernutrition and overweight, including a renewed focus on anemia among adolescent girls, major gaps remain in our understanding of various nutrition issues concerning adolescents. These include various drivers and determinants of the triple burden of malnutrition, evidence-based interventions that are supported by large-scale implementation research and evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents.

Conclusion:

The time has come to position adolescent nutrition as central to development, and mainstream it into health sector plans, strategies, and policies. It is our hope that this issue will stimulate the urgently needed interventions, implementation research and required programs that will safeguard the nutritional wellbeing of today's forgotten generation.

Indonesia Showcases a Prime Example of the Triple Burden of Malnutrition

The Southeast Asia and the Pacific regions contain nearly half of the individuals, worldwide, having the triple burden of malnutrition, characterized by the coexistence of undernutrition, overweight, and micronutrient deficiencies. ¹ Globally, overweight rates have risen fastest in this region. ¹ The changes in dietary intake patterns, such as increased consumption of unhealthy processed foods and a decrease in physical activity associated with industrialization and urbanization, are known to have contributed to an increased prevalence of overweight and obesity. ¹ At the same time, the problem of undernutrition remains undefeated.

Indonesia is a prime example of the triple burden of malnutrition. About 1 in 3 children aged under-5 years is stunted, and 1 in ten 10 children has wasting, while a further 8% are overweight. ² Indonesian adolescents are among the hardest hit, with approximately 1 in 4 adolescent girls having anemia, while nearly 1 in 7 adolescents is overweight or obese. ²

Indonesia’s triple burden of malnutrition is attributed to improved life expectancy due to a shift in the burden of disease from infectious to noncommunicable diseases; rapid economic development accompanied by increased food availability, particularly high-fat, processed foods; and many cities and towns not being pedestrian-friendly and discouraging physical activity. ³ Notably, until recently, few policies and programs were targeting to address the triple burden of malnutrition in Indonesia, particularly among adolescents. Moreover, health care services have been poorly equipped to deal with overweight and obesity, with services to screen, diagnose, and treat overweight and obesity largely lacking.

Actions to Address the Triple Burden of Malnutrition Among Adolescents Are Underway

Indonesia has begun to take major steps to reduce undernutrition, and efforts to address overweight are evolving rapidly. Indonesia joined the Scaling Up Nutrition movement in 2011, a global multi-sectoral, multi-stakeholders movement led by countries to promote action and investment to improve maternal and child nutrition. Undoubtedly, this has helped the country to strengthen the enabling environment for nutrition in Indonesia through high-level advocacy to improve legislative, policy, and regulatory environment and enhance capacity of national and subnational authorities, health workers, and community volunteers to deliver essential nutrition service with quality and coverage. Specifically, prevention of child stunting has gained traction, with stunting having been included as a main development indicator in the National Medium Term Development Plan (2020-2024), demonstrating the government’s commitment to addressing malnutrition and recognizing the need for a multi-sectoral response. ⁴ Importantly, the Government of Indonesia has signaled its firm commitment to address child undernutrition and, in 2017, launched the National Strategy to Accelerate Stunting Reduction to be implemented nationwide. ⁴ In this context, anemia prevention for adolescent girls has received a renewed focus as part of an effort to prevent low birth weight—a strong predictor of child stunting.

Weekly iron-folic acid supplementation has been a national program in Indonesia since 2016 targeting school-going adolescent girls, while not yet covering out of school adolescent girls and boys. While the program has rapidly expanded its reach, the coverage remains relatively low in many parts of the country, and the implementation is faced with various challenges related to supply, monitoring, supportive supervision, and communication. ⁵ Other than the anemia prevention program, however, until recently, few policies were targeted to improve adolescent nutrition in Indonesia from a more holistic standpoint.

Accordingly, since 2017, UNICEF and other stakeholders have been supporting the Government of Indonesia in testing public health interventions and identifying policy options to improve the nutritional status of adolescents in the country. ⁶ Efforts have been made to design an integrated package of nutrition-specific and nutrition-sensitive interventions to address adolescent nutrition. Notably, for the first time, UNICEF together with the government developed a gender-responsive social behavior change communication strategy to improve adolescents’ dietary habits and physical activity. ⁶

Nevertheless, major gaps remain in our understanding of adolescent nutrition in Indonesia, especially among the drivers and determinants of the triple burden of malnutrition, evidence-based interventions that are supported by large-scale implementation research and evaluation, and effective delivery platforms to reach the most vulnerable groups of adolescents. The time has come to position adolescent nutrition as central to development and mainstream it into health sector plans, strategies, and policies. Thus, the present Supplement issue includes research papers focusing on adolescent nutrition in Indonesia.

Roshita et al ⁷ produced evidence on the dietary and physical activity behaviors of adolescent girls and boys and the perspectives of adolescents, their families, and communities on factors influencing these behaviors. The qualitative inquiry highlights the changing dietary and physical activity patterns and habits which contribute to the triple burden of malnutrition among adolescents. These include declining activities both at and outside the school and rapidly deteriorating eating habits such as making their own dietary choices, eating away from home, frequent snacking, and poor dietary diversity. Furthermore, body image perception, an under researched topic in Indonesia, might be an important predictor of eating and physical activity behaviors among adolescents, with gender and nutritional status serving as a significant effect modifier. This was demonstrated in the study by Niswah et al, ⁸ one of the few which determines the body image perception of Indonesian adolescents and its association with their nutritional status, eating, and physical activity behaviors.

Overweight and obesity are increasing at alarming rates in Indonesia. Their determinants are uncovered by Agustina et al, ⁹ who report the prevalence of adolescent overweight and obesity from the Indonesian National Health Survey (INHS) 2013 as well as related psychosocial and lifestyle risk factors. The 5-year trend of adolescent overweight and obesity from the INHS 2013 to 2018 report was also presented. Findings from this study call for future effective interventions on dietary and lifestyle changes among Indonesian adolescents. Other well-known determinants of children’s body weight worldwide include socioeconomic status and the urban/rural divide. Inequalities between siblings, however, such as gender, birth order, and number of siblings, affect body weight variably due to context. To gain a deeper insight into these associations and the extent to which they are affected by maternal education in addition to socioeconomic status within the Indonesian context, Bras ¹⁰ report data from the fifth wave of the Indonesian Family Life Survey (2014/2015) and investigate the relationship between intake of high-calorie foods and body weight. The authors share compelling findings on how maternal education modifies this relationship.

Anemia among adolescents in Indonesia remains a paramount public health concern. Knijff et al ¹¹ document the association between intake of micronutrient-rich foods and anemia among adolescent girls and boys in 2 selected districts in Indonesia, stressing the need to encourage healthy eating behaviors to address the triple burden of malnutrition among adolescents. The cross-sectional study by Agustina et al ¹² involved 335 adolescent girls in West Java province. This study assessed the associations between girls’ knowledge, attitude, and practices and anemia and nutritional outcomes (ie, anemia and linear growth failure). The findings emphasize the need for public health policies to integrate health promotion strategies that contribute to an improved understanding of anemia and linear growth among adolescent girls. While knowledge on anemia goes beyond iron deficiency, etiological factors other than iron have largely been ignored. Iron deficiency is indeed likely to explain a large portion of anemia cases among adolescents; however, a host of other factors may also contribute to it and must be considered. Understanding these additional factors would help to address the problem appropriately. To unravel this, van Zutphen et al ¹³ searched the scientific literature for reports on biological factors brought into connection with anemia in Indonesian adolescents, including intake and absorption of nutrients; biochemical markers; hemoglobinopathies and menorrhagia; infectious diseases; and inflammation. They identify existing knowledge gaps which must be addressed when developing intervention programs aiming to reduce the prevalence of anemia in this age-group.

Following the outstanding knowledge gaps in adolescent nutrition in Indonesia, an overarching multidisciplinary research agenda on this topic is a welcomed and much needed endeavor. In this issue, Sparrow et al ¹⁴ take us through the development of such a research agenda. First, the investigators identify internationally shared knowledge gaps regarding nutritional status of adolescents living in low- and middle-income countries. They state that nutritional outcomes in particular during adolescence are determined by social and economic factors, which cannot be ignored when designing nutritional intervention programs. Based on a desk study, the authors further identify potentially relevant research topics for the Indonesian context, after which a well-attended stakeholder meeting was held in Jakarta in December 2018. During the meeting, representatives from government, academia, nongovernmental organizations, and private companies discussed the knowns and unknowns on adolescent nutrition in Indonesia and expressed future research needs to address the issue. Finally, an online survey was conducted among the attendees of the stakeholder meeting, which led to prioritizing the most pressing research questions. The resulting research agenda is presented and will be useful to all those involved in adolescent nutrition in Indonesia. Moreover, such evidence will help shape future innovative interventions aimed at improving healthy dietary habits, a crucial determinant for an optimal second growth spurt and improved cognition among adolescents as well as a reduced risk of noncommunicable diseases later in life.

Today’s largest cohort in human history has been neglected in worldwide nutrition and health programs for far too long. In Indonesia, where adolescents are among the hardest hit by malnutrition, scientists and decision-makers are slowly but surely drawing attention to this forgotten generation. We hope that this Supplement will spur the drastically needed interventions, implementation research, and relevant programs for the nutritional well-being of adolescents in Indonesia and beyond.