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Child Malnutrition in Indonesia: An Iceberg of Triple Burden

by dr. Eta Auria Latiefa Liaison Officer to Student Organizations CIMSA

Recently, the public was shocked by a fact presented by the Indonesian Pediatrician Association (IDAI) that in 2023, cases of diabetes in children aged 0-18 years have increased by 700% over a 10-year period. Yes, you read that precisely: a 70-fold increase. Many people are wondering, how is it possible the disease that mostly affects adults and the elderly actually occurs in children?

Basically, diabetes mellitus (DM), or what is known as “kencing manis” does have several types. Type 1 DM is a disease that often occurs in children and adolescents due to pancreatic cells being unable to produce insulin, usually caused by an autoimmune process. However, along with lifestyle changes and unhealthy eating patterns of children and their families, there is a tendency for an increase in cases of type 2 DM as well, whose pathophysiology is insulin resistance. The risk factors are related to obesity, genetics, ethnicity, and family history of type 2 DM. From the data presented by IDAI in 2023, more than 59% of children with diabetes are girls. The age of 10-14 years dominates the

2015/2016

epidemiological distribution with 46% of the total reported, followed by the age group of 5-9 years with 31.5%. In addition, as stated by the Head of the IDAI Endocrinology Coordination Work Unit, Muhammad Faizi, the incidence of diabetes in children could be even higher than what has been recorded at this time.

This data might be a new thing for most people, considering that the issue which has been intensified so far is about how to overcome stunting in Indonesia. However, as it turns out, malnutrition in Indonesia is not merely talking about stunting. This country has an overnutrition problem and micronutrient deficiency at the same time as well. The triple burden of malnutrition, the term that represents this condition, is the coexistence of overnutrition (overweight and obesity), undernutrition (stunting and wasting), and micronutrient deficiency at all levels of the population— country, city, community, home, and individual. Even before the COVID-19 epidemic, Indonesian children faced a triple burden of malnutrition. This condition has a direct influence on a kid's physical and mental development and puts them at risk of future diseases. Diverse nutritional intake is critical to a child's growth, hence children in Indonesiarequireimmediatesupport.

How could the triple burden of malnutrition happen? The era of globalization has made almost all activities easier to do. Accessing food easily and following the food trends lead to bad habits in choosing a diet: high fat, low fiber, and lack of nutrients. This is compounded by a sedentary lifestyle. Certainly, inattention to the adequacy of micronutrients, especially in pregnant women and adolescents, can lead to nutritional problems such as anemia. This condition may also affect the next generation which results in stunting and othernutritionalproblems.

Stunting itself is a condition where the zscoreforheightperage(TB/U)islessthan -2 WHO standard. Stunting in toddlers can be known by measuring their length or height, then compared with a standard chart. However, diagnosing stunting is not only concluded by this measurement. Thereareseveralothercharacteristicsthat can be found, such as growth and development delay, poor focus and learning performance, and susceptibility to various infectious diseases. In Indonesia, national initiatives to combat stuntinghavebeennoticeablesince2020, as part of the National Mid-Term DevelopmentPlan2020-2024.

Concomitantly, there is a piece of good news coming from the issue of stunting in Indonesia. Data obtained from the results of the Indonesian Nutrition Status Survey (SSGI) 2022, the stunting rate in 2022 has decreased by 2.8% compared to 2021, from 24.4% to 21.6%. Congratulation! But wait, is that enough? Unfortunately, not yet. The target for the stunting rate in Indonesiais14%.Currently,thereisonly1 provincethatcanachieveastuntingrate below 14%, Bali, with a rate of 10.9% in 2021 and down to 8% in 2022. The three provinces with the largest reduction in stunting are South Kalimantan, North Kalimantan, and South Sumatra. However, even though the stunting rate has generally decreased, there has been an increase in stunting rates in several provinces in Indonesia, such as West Sulawesi, Papua, and West Nusa Tenggara.

On the other hand, according to the 2018 national Basic Health Research Survey (RISKESDAS), about 20% of primary school-aged children and 14% of Indonesian adolescents are obese or overweight. Overnutrition is a kind of malnutrition caused by an overabundance ofnutrients,resultinginabuildupofbody fatthatcompromiseshealth.Forchildren under the age of 5, overweight is defined as weight-for-height (TB/BB) greater than 2 standard deviations above the WHO Child Growth Standards median, while obesity is defined as weight-for-height (TB/BB) greater than 3. Meanwhile, for children aged 5 to 19, overweight is defined as BMI-for-age (BMI/U) greater than 1 standard deviation, and obesity is defined as BMI-for-age (BMI/U) larger than 2 standard deviations over the WHO GrowthReferencemedian. a healthy lifestyle, such as paying attention to nutritional intake that is consumed with balanced nutrition guidelines, limiting consumption of sugar, salt, and fat, and doing regular physical activity (150 minutes per week). Health workers also need to provide comprehensive education to the community in creating government programs successful. Various government efforts have been intensified to address thisnutritionalproblem,suchaseducation on exclusive breastfeeding, provision of protein-rich complementary foods, management of toddlers with nutritional problems, and increasing coverage of mandatory immunization. For pregnant women and teenagers, the blood supplement program is also an effort to prevent nutritional problems from occurringinthefuture.

The third issue is micronutrient deficiencies. Globally, data from WHO estimated 42% of children under 5 years of age and 40% of pregnant women worldwide are anemic. This condition can be caused by a lack of iron, folate, and vitamin B12. Micronutrients, vitamins and minerals that the body needs in minute quantities, have much influence on a body's health. Micronutrients are crucial, and deficiencies in any of them can result in serious and even life-threatening illnesses. Lack of Iron, vitamin A, and iodine deficiencies are the most frequent allovertheworld,especiallyinyoungsters andpregnantwomen.

Some other parties also give response to malnutrition in Indonesia. UNICEF offers technical support to the government of Indonesia in order to improve food security and reduce child wasting and stunting by 14% by 2024. In addition, Indonesia joined the SUN Business Network(SBN)in2015,whichbillsitselfas the world's biggest business sector nutrition program. The corporate sector mobilizes within this network to meet national nutrition targets through educationandfortifiedfooditems.

Well,themostimportantquestionis:what should we do to overcome this triple burdenofmalnutrition?Theeasiestwayis tostartwithourselves.Wecanimplement

In conclusion, the triple burden of malnutrition is an iceberg of a serious problemthatneedsmoreconcernfromall parties. Malnutrition in its many manifestations was traditionally regarded and treated as a separate public health concern, but the new emerging truth is that undernutrition and overnutrition are interrelated, necessitating double-duty interventions that concurrently address morethanonedimension.